Anthem Blue Cross Connecticut CG-MED-28 Iontophoresis Form

This document addresses the use of iontophoresis, the passing of an ionized substance through intact skin by the application of a direct electrical current. It has been evaluated as a technique for drug delivery and proposed as a treatment for hyperhidrosis.

Clinical Indications

Medically Necessary:

Iontophoresis is considered medically necessary for any of the following indications:

1. For the administration of local anesthesia prior to a venipuncture or dermatologic procedure; or
2. In the treatment of primary or secondary hyperhidrosis only for individuals who have tried prescription strength antiperspirants without success and meet any ONE of the following criteria:
   1. Presence of medical complications or skin maceration with secondary infection; or
   2. Significant functional impairment, as documented in the medical record.

Not Medically Necessary:

The use of iontophoresis is considered not medically necessary when the above criteria are not met and for all other indications, including, but not limited to treatment of temporomandibular disorders, and as a technique for drug delivery involving the administration of nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids as treatment for inflammatory musculoskeletal disorders.