Anthem Blue Cross ConnecticutCommercial Clinical Policy

Anthem Blue Cross Connecticut CG-MED-28 Iontophoresis Form


Iontophoresis for local anesthesia

Indications

(126299) Is the iontophoresis procedure being administered for local anesthesia prior to a venipuncture or dermatologic procedure? 

Iontophoresis for hyperhidrosis

Notes: Only one of the criteria needs to be met for coverage.

Indications

(126300) Has the patient tried prescription strength antiperspirants without success? 
(126301) Does the patient have medical complications or skin maceration with secondary infection due to hyperhidrosis? 
(126302) Does the patient have significant functional impairment due to hyperhidrosis, as documented in the medical record? 

Iontophoresis for other indications

Notes: Included non-covered indications: temporomandibular disorders or drug delivery involving NSAIDs/corticosteroids for inflammatory musculoskeletal disorders.


Contraindications

(126303) Is iontophoresis requested for any indication other than local anesthesia before venipuncture/dermatologic procedures or primary/secondary hyperhidrosis after failing prescription strength antiperspirant use? 
Effective Date

01/03/2024

Last Reviewed

11/09/2023

Original Document

  Reference



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.