Anthem Blue Cross Connecticut CG-SURG-116 Surgical Treatment of Hyperhidrosis Form

This document addresses various surgical treatments of hyperhidrosis, a condition characterized by excessive sweating.

Note: This document does not address the use of iontophoresis for the treatment of hyperhidrosis. Please refer to the following document for that information:

• CG-MED-28 Iontophoresis

Note: The use of botulinum toxin is not addressed in this document. For information regarding the use of  botulinum toxin, refer to applicable guidelines used by the plan.

Clinical Indications

Medically Necessary:

Treatment of primary axillary or palmar hyperhidrosis with endoscopic thoracic sympathectomy is considered medically necessary when both of the following criteria (A and B) have been met:

1. It has been adequately documented that all efforts at nonsurgical therapy have failed; and
2. Either of the following:
   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:

Treatment of hyperhidrosis is considered not medically necessary when the above criteria are not met.

Treatment of plantar hyperhidrosis with thoracic or lumbar sympathectomy or sympathetic block is considered not medically necessary in all cases.

All other surgical therapies for hyperhidrosis are considered not medically necessary, including but not limited to:

• Axillary liposuction; or
• Laser treatment; or
• Microwave energy; or
• Resection of axillary sweat glands.