Hyperhidrosis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for endoscopic thoracic sympathectomy. Findings: The physician reviewer found that the patient has not tried some standard medical treatments for hyperhidrosis including oral anticholinergic agents or Botox injections, but there is no reasonable expectation that these agents will have any significant or long-lasting benefit for this patient since he has already failed topical Drysol prescription grade aluminum chloride. The oral anticholinergic treatments will dry the entire body, and the patient’s mouth and eyes will likely dessicate long before any improvement is noted in the hands or axillae. In addition, Botox injections are U.S. Food and Drug Administration (FDA) approved for the axillae, but not the hands.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for bilateral endoscopic thoracic sympathectomy and bilateral endoscopic lumbar sympathectomy. Surgical intervention may be indicated for patients with severe, refractory hyperhidrosis who have not achieved adequate relief with conservative and medical therapies. Clinical literature supports the use of endoscopic sympathectomy in appropriately selected patients with advanced disease, demonstrating meaningful improvement in symptoms and quality of life. In this case, the patient has severe, refractory hyperhidrosis with significant functional impairment and has failed prior medical management.

Where the denial was upheld

A 63-year-old female enrollee has requested microendoscopic thoracic sympathectomy and subdermal laser ablation for treatment of her hyperhidrosis. Findings: The physician reviewer found that hyperhidrosis is excessive sweating beyond that required to return body temperature to normal. It can be localized or generalized, commonly affecting the axillae, palms, soles or face, and trunk, and can have a substantial negative effect on a patient’s quality of life (Coutinho dos Santos, et al). Various treatment options are available, including topical or systemic medications, iontophoresis, regional sympathetic nerve block, botulinum toxin injection, and surgical interventions (Solish, et al). Subdermal laser ablation has been used in a limited number of patients with axillary hyperhidrosis (Kotlus, et al).

Nature of Statutory Criteria/Case Summary: An enrollee has requested autonomic function testing (CPT 95943) for evaluation of the enrollee, who has a history of lightheadedness and extreme sweating. Findings: Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting. This patient has had lightheadedness on standing, suggesting orthostasis. Physical examination revealed a carotid bruit. No orthostatic vital signs are documented. Hyperhidrosis is commonly idiopathic, but can be symptomatic of many medical conditions, such as acromegaly, anxiety, cancer, medications, and hyperthyroidism amongst others. Autonomic neuropathy can cause reduced sweating, and would be unlikely to cause focal palmar and plantar hyperhidrosis. In this patient’s case, the clinical documentation is inadequate to suggest significant autonomic dysfunction.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving hyperhidrosis, then check the rights and deadlines that apply to your plan.