II-55-012

Medical Policy:

II-55-012

Topic:

Selected Treatments for Hyperhidrosis

Section:

Medicine

Effective Date:

November 25, 2024

Issued Date:

November 25, 2024

Last Revision Date:

October 2019

Annual Review:

November 2024

This policy addresses selected treatments for hyperhidrosis, a condition characterized by excessive sweating of the underarms (axillae), palms of the hand (palmar), feet (plantar), face and/or scalp (craniofacial).

Definitions

Aluminum chloride 20% topical solution: The aluminum chloride product Drysol™ is FDA approved to be used as an aid in management of hyperhidrosis. It is available by prescription.

Hyperhidrosis: Excessive sweating beyond a level required to maintain normal body temperature.

Primary hyperhidrosis may be caused by overactivity of the sympathetic nervous chain or overactivity of the sweat glands themselves.
Secondary hyperhidrosis results from underlying causes including response to some drugs (e.g., tricyclic antidepressants, and selective serotonin reuptake inhibitors [SSRIs], or from underlying diseases or conditions such as febrile diseases, diabetes mellitus, or menopause. Treatment of secondary hyperhidrosis generally focuses on treating the underlying cause, such as discontinuation of certain drugs or hormone therapy.
Gustatory hyperhidrosis is excessive sweating around the lips, nose, and forehead. This type of hyperhidrosis occurs normally with the consumption of hot, spicy foods. However, severe pathological gustatory sweating may be secondary, caused by sympathetic nerve damage and conditions such as Frey syndrome, encephalitis, syringomyelia, diabetic neuropathies, herpes zoster parotitis, and parotid abscess.

Microwave treatment is designed to heat tissue at the dermal-hypodermal interface, the location of the sweat glands. Prior to treatment, which is administered in the physician's office, the patient receives local anesthesia. Treatment generally consists of two sessions of approximately one hour in duration. One microwave device, the miraDry^® System, was cleared by the FDA through the 510(k) process as substantially equivalent to predicate devices for treating primary axillary hyperhidrosis.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

I. Endoscopic Transthoracic Sympathectomy (ETS) or Thoracic Sympathectomy

Endoscopic transthoracic sympathectomy (ETS) or thoracic sympathectomy may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL criteria are met:

Primary hyperhidrosis occurs in ONE OR MORE of the following specific foci:
- Axillary; OR
- Palmar; OR
- Craniofacial;
AND ONE of the following criteria are met:
- Chronic dermatological complications secondary to hyperhidrosis (e.g. skin maceration with secondary infection, dermatitis/fungal infection); OR
- Significant disruption of professional/personal life or significant functional impairment as a result of hyperhidrosis, as documented in the medical record;
AND BOTH of the following criteria are met:
- Topical prescription aluminum chloride 20% administered for a minimum of one month is contraindicated, poorly tolerated, or ineffective; AND
- Failure, contraindication, or intolerance to botulinum toxin therapy.

All other uses of endoscopic transthoracic sympathectomy or thoracic sympathectomy for the treatment of hyperhidrosis including but not limited to treatment of plantar hyperhidrosis are considered EXPERIMENTAL/INVESTIGATIVE due to the lack of clinical evidence demonstrating an impact on improved health outcomes.

II. Tympanic Neurectomy

Tympanic neurectomy may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:

As a treatment for secondary gustatory hyperhidrosis;
AND ONE of the following criteria are met:
- Chronic dermatological complications secondary to hyperhidrosis (e.g. skin maceration with secondary infection, dermatitis/fungal infection); OR
- Significant disruption of professional/personal life or significant functional impairment as a result of hyperhidrosis, as documented in the medical record;
AND Topical prescription aluminum chloride 20% administered for a minimum of one month is contraindicated, poorly tolerated, or ineffective.

All other uses of tympanic neurectomy for the treatment of hyperhidrosis are considered EXPERIMENTAL/INVESTIGATIVE due to the lack of clinical evidence demonstrating an impact on improved health outcomes.

III. EXPERIMENTAL/INVESTIGATIVE Procedures

The following procedures for hyperhidrosis are considered EXPERIMENTAL/INVESTIGATIVE due to the lack clinical evidence indicating an impact in improved outcomes, including but not limited to:

Liposuction (e.g. axillary);
Coagulation of lymph glands (e.g. axillary);
Microwave treatment;
Radiofrequency ablation;
Subdermal laser treatment.

15877 15878 32664 64804 64809 69676

Denial Statements

No additional statements.

Links

Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.

Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.

Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.

Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.

Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.

These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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