Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Axillary hyperhidrosis

Treatment: Botox 100u vial

The insurer is denied coverage for Botox 100u vial. The denial is reversed. 

The patient is a male with a history of axillary hyperhidrosis. An examination noted documents the patient reported severe underarm sweating despite Drysol and wipes, and that it was socially debilitating. An examination note states the patient has had severe sweating for several years and has tried Drysol and other treatments which were discontinued due to rashes. 

An undated Hyperhidrosis Disease Severity Scale (HDSS) Measure form completed by the claimant reports his underarm sweating is intolerable and always interferes with his daily activities. The form notes the patient has tried all deodorants and has tried wipes, and that he is self-conscious about his excessive sweating. The appeal letter by a dermatologist, states the claimant suffers from severe primary axillary hyperhidrosis which seriously impairs his ability to carry out the kinds of activities we all take for granted in our daily lives. It is not adequately managed with topical agents and requires treatment with Botulinum toxin Type A. The patient is still experiencing excessive sweating, body odor and staining of clothes and is extremely embarrassed by the smell and staining produced by the excessive sweating. The RPA states she believes Botox 100 units per axilla will help the patient. 

Per McConaghy, J. R., et al. (2018), "The Hyperhidrosis Disease Severity Scale is a validated survey used to grade the tolerability of sweating and its impact on quality of life...Local surgery and endoscopic thoracic sympathectomy should be considered in severe cases of hyperhidrosis that have not responded to topical or medical therapies."
Nawrocki, S., & Cha, J. (2019) note that "Hyperhidrosis (HH) is a chronic disorder of excess sweat production that may have a significant adverse effect on quality of life. A variety of treatment modalities currently exist to manage HH...Botulinum toxin injections are administered at the dermal-subcutaneous junction and serve as a safe and effective treatment option for focal HH." Per Grabell, D.A., Hebert, A.A. (2017), "Botulinum toxin is an acetylcholine release inhibitor and a neuromuscular blocking agent that is commercially available in the United States [42, 43]. Each botulinum toxin (OnabotulinumtoxinA, AbobotulinumtoxinA, and IncobotulinumtoxinA) has different characteristics with variable clinical equipotency ratios that are influenced by the severity of the underlying disease [44]]...Patients who respond to treatment can have consistent reduction of axillary sweat for greater than 5 months with repeat dosing shown to be safe with equal or potentially increased efficacy [4648]."     

According to Smith, et al. (2020), "Treatment with prescription antiperspirants, such as 20% aluminum chloride hexahydrate or 6.25% aluminum chloride hexahydrate, may provide adequate therapy for patients with axillary hyperhidrosis that fails to respond to nonprescription antiperspirants" the patient has even tried and failed QBrexza which is a prescription and anticholinergic medication. The medical literature does not state that an individual needs to be on a topical antiperspirant for a year to determine if it is going to be effective. Usually, effectiveness for a topical antiperspirant will be determined after a 3 months of use. The claimant has tried and failed topical medications after several months of use. This is an adequate time to determine if topical therapy is effective. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

Based on the above, the medical necessity for Botox 100u vial is substantiated.  The insurer's denial is reversed.