CG-SURG-116 Surgical Treatment of Hyperhidrosis

This policy addresses surgical treatment of hyperhidrosis, primarily endoscopic thoracic sympathectomy (ETS). ETS is covered as medically necessary only for primary axillary or palmar hyperhidrosis after documented failure of nonsurgical treatments and when there is either medical complications/skin maceration with secondary infection or significant functional impairment documented in the record. Surgery is not covered if these criteria are not met; treatment of plantar hyperhidrosis with thoracic or lumbar sympathectomy or sympathetic block is not covered in any case; and other surgical procedures (e.g., axillary liposuction, laser) are considered not medically necessary.

"Treatment of primary axillaryor palmar hyperhidrosis with endoscopicthoracicsympathectomy is consideredmedically necessarywhen both of the following criteria (A and B) have been met:"

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