Description

Hyperhidrosis is a condition characterized by excessive sweating beyond what is required to regulate the body temperature. Primary or focal hyperhidrosis occurs in specific body areas, such as the axilla (underarms), face, lower back, palms of the hands (palmar) and soles of the feet (plantar). Secondary hyperhidrosis, also called generalized hyperhidrosis, may be a side effect of a medication or an underlying medical condition (eg, infection, malignancy, metabolic or thyroid disorder). Alleviating symptoms of secondary hyperhidrosis involves treating the underlying condition. Primary hyperhidrosis may be treated with nonsurgical or surgical methods.

Nonsurgical Treatments

• Electromagnetic microwave energy (microwave thermolysis) is purported to deliver microwave energy to axillary skin at specified frequency and power levels to destroy sweat glands. One example of such system is the noninvasive miraDry which is intended for use in the treatment of primary axillary hyperhidrosis and is not indicated for use in the treatment of hyperhidrosis related to other body areas or generalized hyperhidrosis. (Refer to Coverage Limitations section)
• Iontophoresis involves placing the hands or feet on a pad moistened with tap water or into a water bath with electrodes attached. Treating axillary hyperhidrosis requires the placement of pads attached to electrodes under the arms. When the device is turned on, a mild electrical current interacts with the sweat glands and ducts stopping or decreasing sweat secretion. Treatments are repeated over several days until sweating is reduced to a comfortable level. Individuals may require a maintenance schedule and repeat sessions are often required if excessive sweating returns. Prescription medications may be added to the water bath if iontophoresis using water alone has proven unsuccessful. Iontophoresis devices used for in-office or in-home treatment of hyperhidrosis include, but may not be limited to Dermadry, Drionic, Hidrex or Fischer.
• Medications include the use of oral anticholinergics, benzodiazepines and beta blockers, injectable Botulinum Toxin (Botox) and topical agents such as prescription- strength aluminum chloride (antiperspirants). For information regarding medications for hyperhidrosis treatment, please refer to the Botox (Botulinum Toxin) and Qbrexza (glycopyrronium) Pharmacy Coverage Policies.

Surgical Treatments

Excision of the axillary sweat glands involves the surgical removal of limited areas of skin and selected sweat glands. Procedures can be grouped into three categories:

• Excision of both skin and underlying sweat glands (the most radical/extensive approach)
• Removal of subcutaneous glands through a small incision by liposuction or by scraping the glands from the undersurface of the dermis with a curette
• A combination of the two approaches described above in which a limited central excision is combined with curettage and/or liposuction of the surrounding axillary subcutaneous glands

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

For information regarding liposuction as the sole method for axillary sweat gland removal, refer to the Coverage Limitations section.

There are two approaches for performing sympathectomy, the surgical interruption of sympathetic nerve pathways:

• Endoscopic thoracic sympathectomy (ETS) may also be referred to as video-assisted thoracic (or thoracoscopic) surgery (VATS) sympathectomy and is performed by inserting instruments and a scope with a camera into the chest via multiple small incisions under the axilla. The lung is temporarily collapsed so the surgeon can cut or otherwise destroy the nerve paths associated with the overactive sweat glands. The same procedure is repeated on the other side of the body. Side effects, especially compensatory hyperhidrosis in other parts of the body, may reduce long term satisfaction with this procedure. Sweating returns in approximately 50% of individuals.
• Prior to cauterizing (cutting and sealing) a portion of the sympathetic nerve chain that runs down the inside of the chest cavity. This operation permanently interrupts the nerve signal that is causing the body to sweat excessively and can be performed in either of the two sympathetic trunks. Each trunk is divided into three regions: cervical (neck), thoracic (chest) and lumbar (lower back). Sympathectomy is commonly targeted to the upper thoracic region.

Coverage Determination

Please refer to the member's applicable pharmacy benefit to determine benefit availability and the terms and conditions of coverage for medication for the treatment of hyperhidrosis.

Office-Based Iontophoresis

Humana members may be eligible under the Plan for medically supervised office-based iontophoresis when the following criteria are met:

• Primary palmar or plantar hyperhidrosis; AND
• Presence of a chronic skin condition such as dermatitis, intertrigo or fungal infection; AND
• The chronic skin condition is refractory to at least three consecutive months of medically supervised treatment (e.g., drying agents, medications [oral, injectable or topical], skin care); AND
• The hyperhidrosis is unresponsive to at least two of the following prescribed pharmacotherapies:
  • Oral anticholinergics; OR
  • Oral benzodiazepines, OR
  • Oral beta blockers; OR
  • Topical glycopyrronium; OR
  • Topical prescription-strength aluminum chloride (antiperspirants)

Home Iontophoresis

Commercial Plan members: requests for home iontophoresis devices require review by a medical director.

Humana members may be eligible under the Plan for home iontophoresis devices when the above criteria are met, long term use is expected, and the individual has responded to four weeks of in-office iontophoresis therapy.

Repair/Replacement of Home Iontophoresis Equipment

Please consult the member's individual certificate regarding Plan coverage for repairs/maintenance and replacement of DME.

In the absence of certificate language, please refer to the Repair/Replacement section in the Durable Medical Equipment (DME) Medical Coverage Policy.

Axillary Sweat Gland Excision

Humana members may be eligible under the Plan for axillary sweat gland excision when ALL of the following criteria are met:

• Primary axillary hyperhidrosis refractory to management with all nonsurgical options (oral medications, topical medications, iontophoresis); AND
• Presence of a chronic skin condition such as dermatitis, intertrigo or fungal infection that has not responded to at least six consecutive months of previous documented medical treatment

ETS, VATS or Sympathectomy

Humana members may be eligible under the Plan for ETS, VATS or sympathectomy when ALL of the following criteria are met:

• Primary axillary or palmar hyperhidrosis refractory to management with all nonsurgical options (oral medications, topical medications, iontophoresis); AND
• Presence of a chronic skin condition such as dermatitis, intertrigo or fungal infection that has not responded to at least six consecutive months of previous documented medical treatment

Coverage Limitations

Humana members may NOT be eligible under the Plan for nonsurgical or surgical hyperhidrosis treatments for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for nonsurgical or surgical hyperhidrosis treatments by any of the following methods:

• ETS, VATS or sympathectomy for the treatment of craniofacial or plantar hyperhidrosis; OR
• Liposuction as the sole method of removing axillary sweat glands; OR
• Microwave or electromagnetic energy (microwave thermolysis)

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Additional Information

Additional information about focal (primary) hyperhidrosis, general (secondary) hyperhidrosis and hyperhidrosis treatment options may be found from the following websites:

• Background
  • National Library of Medicine

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.