REVIEW REQUEST FOR

Treatment of Hyperhidrosis

Provider Data Collection Tool Based on Medical Policies 8.01.19; MED.00032

Policy Last Review Date: 09/2009; 11/19/2009 / Policy Effective Date: 09/2010; 01/01/2010 / Provider Tool Effective Date: 03/25/2011
Individual’s Name: / Date of Birth:
Insurance Identification Number: / Individual’s Phone Number:
Ordering Provider Name & Specialty: / Provider ID Number:
Office Address:
Office Phone Number: / Office Fax Number:
Rendering Provider Name & Specialty: / Provider ID Number:
Office Address:
Office Phone Number: / Office Fax Number:
Facility Name: / Facility ID Number:
Facility Address:
Date/Date Range of Service: / Place of Service: Home Inpatient
Outpatient Other:
Service Requested (CPT if known):
Diagnosis (ICD-9 if known):

Please check all that apply to the individual:

Individual has primary hyperhidrosis

Individual has secondary hyperhidrosis

Individual has medical complications or skin maceration with secondary infection

Individual has a significant functional impairment that is documented in the medical records

Request is for iontophoresis for an individual who has tried prescription strength antiperspirants without success

Request is for botulinum toxin and the individual has failed a 6 month trial of any one or more types of non surgical treatments (check all that apply)

Topical dermatologics (i.e., aluminum chloride, tannic acid, glutaraldehyde, anticholinergics)

Systemic anticholinergics

Tranquilizers

Non steroid anti-inflammatory drugs

Other (please list) ______

Request is for botulinum toxin and the individual’s condition is related to surgical complications and significant functional impairment is present

Request is for thoracic sympathectomy : (check all that apply)

Individual has primary axillary hyperhydrosis

Individual has palmar hyperhydrosis

Individual has plantar hyperhydrosis

It is documented that the individual has failed all efforts at non surgical therapy

Other (please list) ______

Request is for lumbar sympathectomy for plantar hyperhidrosis

Request is for sympathetic block for plantar hyperhidrosis

Request is for axillary liposuction for hyperhidrosis

Request is for resection of axillary sweat glands for hyperhidrosis

Other (please list) ______

This request is being submitted:

Pre-Claim

Post–Claim. If checked, please attach the claim or indicate the claim number

I attest the information provided is true and accurate to the best of my knowledge. I understand that Anthem may perform a routine audit and request the medical documentation to verify the accuracy of the information reported on this form.

______

Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)* Date

*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted

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