| Highmark Commercial Medical Policy - Pennsylvania |
| Medical Policy: | S-178-022 |
| Topic: | Treatment of Hyperhidrosis |
| Section: | Surgery |
| Effective Date: | September 25, 2017 |
| Issue Date: | July 23, 2018 |
| Last Reviewed: | July 2018 |
|
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. |
Treatment for primary focal hyperhidrosis may be considered medically necessary when ANY ONE of the following general criteria have been met:
AND
In addition to ANY ONE of the above criteria, BOTH of the following criteria must be met to be considered medically necessary:
Focal Regions and corresponding treatments that may be considered medically necessary when ANY ONE of the below criteria have been met:
Axillary Region
NOTE: Sympathectomy for hyperhidrosis treatment of axillary and palmar regions requires an inpatient stay.
Initial authorization for botulinum toxin A (OnabotulinumtoxinA) for axillary hyperhidrosis will expire in 3 months from the original authorization date for any diagnosis. Additional authorization may be given if documentation of an objective measurable effect is provided indicating clinical improvement of the condition. Absence of clinical improvement of axillary hyperhidrosis will be considered not medically necessary for further injections of botulinum toxin A (OnabotulinumtoxinA)
Axillary liposuction and microwave treatment for axillary hyperhidrosis are considered experimental/investigational, and therefore non-covered.
Axillary liposuction as treatment for primary hyperhidrosis is considered experimental/ investigational, and therefore non-covered.
Palmar Region
Botulimnum toxin B (RimabotulinumtoxinB), microwave treatment and radiofrequency ablation for palmar hyperhidrosis are considered experimental/investigational, and therefore non-covered.
Plantar Region
Botulinum toxin, lumbar sympathectomy and microwave treatment for plantar hyperhidrosis are considered experimental/investigational, and therefore non-covered.
Craniofacial Region
Botulinum toxin, iontophoresis, and microwave treatment for craniofacial hyperhidrosis are considered experimental/investigational, and therefore non-covered.
Secondary Hyperhidrosis: Secondary Gustatory Hyperhidrosis
The following treatments may be considered medically necessary for the treatment of severe gustatory hyperhidrosis when the above general criteria have been met:
Botulinum toxin and iontophoresis for severe gustatory hyperhidrosis are considered experimental/investigational, and therefore not covered.
Refer to medical policy I-11 Botulinum Toxin (Chemodenervation)for additional information.
Treatment of hyperhidrosis is considered not medically necessary in the absence of functional impairment or medical complications, and therefore non-covered.
| Place of Service: Inpatient/Outpatient |
Treatment of Hyperhidrosis is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
| The policy position applies to all commercial lines of business |
| Denial Statements |
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
| Links |
