Iontophoresis or electrophoresis, (e.g., Drionic® device) is ineffective (see CPB 0229 - Iontophoresis) (a trial of botulinum toxin can be substituted for iontophoresis in persons with predominantly axillary hyperhidrosis -- see CPB 0113 - Botulinum Toxin); and
Significant disruption of professional and/or social life has occurred because of excessive sweating; and
Topical aluminum chloride or other extra-strength antiperspirants are ineffective or result in a severe rash; and
Unresponsive or unable to tolerate pharmacotherapy prescribed for excessive sweating (e.g., anti-cholinergics, beta-blockers, benzodiazapines) if sweating is episodic.
Aetna considers thoracoscopic sympathectomy cosmetic for excessive spontaneous facial blushing. Facial blushing (flushing) is considered a cosmetic indication as it does not result in functional impairment.
Aetna considers thoracoscopic sympathectomy experimental and investigational for all other indications becasue its effectiveness for indications other than the ones listed above has not been established.
Aetna considers left thoracoscopic sympathectomy experimental and investigational for cardiac denervation in persons with ventricular arrhythmias, and heart failure because the effectiveness of this approach for these indications has not been established.
A report by the Finnish Office of Health Technology Assessment systematically evaluated the literature on the safety and effectiveness of thoracoscopic sympathectomy for treatment of sweating and for treatment of social phobia (Malmivaara et al, 2005). Thoracoscopic sympathectomy aims to reduce excessive sweating of the face and hands and facial flushing by interrupting stimulation of sweat glands by the sympathetic nervous system. The treatment is performed as an endoscopic procedure, where the upper thoracic chain of the sympathetic nerve trunk is transsected or clamped.
The authors stated that it is difficult to conduct even a qualitative synthesis of studies of thoracoscopic sympathectomy, due to poor reporting of patient characteristics and variation among studies in the reporting of outcomes (Malmivaara et al, 2005). In addition, the authors found most of the studies to be of poor methodologic quality. The authors stated, however, that available literature suggests that thoracoscopic sympathectomy reduces excessive sweating of the palms and facial flushing. Patient satisfaction was reported as good or moderately good. The authors identified only 1 study that followed subjects for more than 2 years.
The reported rates of acute post-operative complications following endoscopic thoracic sympathetomy varided widely among studies studies (Malmivaara et al, 2005). Acute post-operative complications, some severe, occurred in as many as 10 % of subjects. The most commonly reported chronic complication was compensatory sweating below the breast level, often with substantial resultant disability. Other chronic complications included dryness of the face or palms and gustatory sweating. The authors noted that, due to wide variation in the reporting of complications, it is probable that these complications have been under-reported in most series.
The authors concluded that "due to lack of controlled trials there is no reliable evidence for the effectiveness of endoscopic thoracic sympathectomy for excessive sweating in the face and hands or for flushing of the face" (Malmivaara et al, 2005). The authors also found no reliable evidence of the effectiveness of endoscopic thoracoscopic sympathectomy for social phobia. The authors concluded that endoscopic thoracic sympathectomy is associated with significant immediate and long-term adverse effects.
A follow-up article to the FinOHTA assessment (Malmivaara et al, 2007) re-affirmed these earlier findings, concluding that: "The evidence for the effectiveness of ETS [endoscopic thoracic sympathectcomy] is weak. The intervention is associated with severe immediate complications in some patients and persistent adverse effects for many." The methodological quality and the reporting of clinically relevant characteristics were poor. The quality scores of the included studies ranged from 0 to 8; only 3 studies scored 6 or more. The authors stated that blushing and excessive sweating decreased after ETS in all studies, but no further details were reported. Complications following ETS included pneumothorax and/or haemothorax and Horner's syndrome in some patients in almost all studies. Compensatory excessive sweating was observed in 50 % or more of patients in 13 of the 15 studies, and was considered to cause significant disability in 3 to 15 % of those who experienced it.
A review by the Royal Australasian College of Surgeons (Watt et al, 2009) concluded that "[a] lack of high quality randomised trial evidence on ETS means that it is difficult to make a judgment on the safety and effectiveness of this technique", and that "[t]here is potentially a number of safety issues associated with this procedure."
Patients with palmar hyperhidrosis who fail topical therapies and iontophoresis, and who do not tolerate or get relief from botulinum toxin, can be treated effectively with endoscopic thoracic sympathectomy (Smith, 2008). Side effects, especially compensatory hyperhidrosis in other parts of the body, may reduce long-term patient satisfaction with this procedure. Endoscopic thoracic sympathectmy can also be used for axillary hyperhidrosis, but the relapse rate is high.
Hofferberth et al (2014) reported the outcomes of a single-institution experience using video-assisted thoracoscopic left cardiac sympathetic denervation as an adjunctive therapeutic technique in pediatric and young adult patients with life-threatening ventricular arrhythmias. These investigators conducted a retrospective clinical review of all patients who underwent left cardiac sympathetic denervation by means of video-assisted thoracoscopic surgery at the authors’ institution. From August 2000 to December 2011, a total of 24 patients (13 with long QT syndrome, 9 with catecholaminergic polymorphic ventricular tachycardia, and 2 with idiopathic ventricular tachycardia) were identified from the cardiology database and surgical records. There were no intra-operative complications. The median post-operative length of stay was 2 days (range of 1 to 32 days). There were no major peri-operative complications. Longer-term follow-up was available in 22 of 24 patients at a median follow-up of 28 months (range of 4 to 131 months). Sixteen (73 %) of the 22 patients experienced a marked reduction in their arrhythmia burden, with 12 (55 %) becoming completely arrhythmia-free after sympathectomy. Six (27 %) of the patients were non-responsive to treatment; each had persistent symptoms at follow-up. The authors concluded that video-assisted thoracoscopic left cardiac sympathetic denervation can be safely and effectively performed in most patients with life-threatening ventricular arrhythmias. They stated that this minimally invasive procedure is a promising adjunctive therapeutic option that achieves a beneficial response in most symptomatic patients. These preliminary findings need to be validated by well-designed studies.
De Ferrari and Schwartz (2014) stated that heart failure (HF) is characterized by an autonomic imbalance with withdrawal of vagal activity and increased sympathetic activity. Novel non-pharmacological approaches to HF aimed at increasing vagal activity are being proposed. Left cardiac sympathetic denervation (LCSD) has been shown to modify favorably the outcome of several disorders characterized by life-threatening arrhythmias triggered by increased sympathetic activity. These investigators discussed the rationale and the limited experimental and clinical experience suggesting a potential role for LCSD in the treatment of patients with advanced HF. Possible future clinical applications of LCSD may include HF patients who are intolerant to beta-adrenergic blockade, HF patients who have frequent implantable cardioverter-defibrillator shocks, and HF patients in countries where the likelihood of receiving a device is limited, but the capability to perform a one in a lifetime procedure is present.
An UpToDate review on “Management of refractory heart failure” (Colucci, 2015) does not mention thoracoscopic sympathectomy as a therapeutic option.
Costello et al (2015) stated that congenital ion channel disorders, including congenital long QT syndrome (LQTS), cause significant morbidity in pediatric patients. When medication therapy does not control symptoms or arrhythmias, more invasive treatment strategies may be necessary. These researchers examined their institution's clinical experience with surgical cardiac denervation therapy for management of these arrhythmogenic disorders in children. An institutional review board-approved retrospective review identified 10 pediatric patients with congenital ion channelopathies who underwent surgical cardiac denervation therapy at a single institution between May 2011 and April 2014; 8 patients had a diagnosis of congenital LQTS, 2 patients were diagnosed with catecholaminergic polymorphic ventricular tachycardia (CPVT). All patients underwent sympathectomy and partial stellate ganglionectomy via video-assisted thoracoscopic surgery (VATS). Six of the 10 patients had documented ventricular arrhythmias pre-operatively, and 70 % of the patients had pre-operative syncope. The corrected QT interval decreased in 75 % of patients with LQTS following sympathectomy. Post-operative arrhythmogenic symptoms were absent in 88 % of congenital LQTS patients, but both patients with CPVT continued to have symptoms throughout the duration of follow-up. All patients were alive after a median follow-up period of 10 months. The authors concluded that surgical cardiac denervation therapy via VATS is a useful treatment strategy for congenital LQTS patients who failed medical management, and its potential benefit in the management of CPVT is unclear. They stated that a prospective comparison of the effectiveness of surgical cardiac denervation therapy and implantable cardioverter-defibrillator use in congenital ion channelopathies is timely and crucial.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
Thoracoscopy, surgical; with thoracic sympathectomy
Other CPT codes related to the CPB:
Chemodenervation of eccrine glands; both axillae
Application of a modality to one or more areas; iontophoresis, each 15 minutes
Other HCPCS codes related to the CPB:
Botulinum toxin type A, per unit
Botulinum toxin type B, per 100 units
ICD-9 codes covered if selection criteria are met:
Causalgia of upper limb
Causalgia of lower limb
Long QT syndrome [in persons who have failed medical therapy and have frequency ICD shocks despite medications]
Paroxysmal ventricular tachycardia [catecholaminergic polymorphic, in persons who remain symptomatic despite maximal medical therapy]
Primary focal hyperhidrosis [intractable, disabling - see criteria]
Secondary focal hyperhidrosis [intractable, disabling - see criteria]
ICD-9 codes not covered for indications listed in the CPB:
Paroxysmal ventricular tachycardia
Unspecified paroxysmal tachycardia
428.0 - 428.9
Other ICD-9 codes related to the CPB:
Unspecified disorder of the autonomic nervous system [shoulder-hand syndrome]
Unspecified circulatory system disorder [vascular occlusive disease]
The above policy is based on the following references:
Zacherl J, Huber ER, Imhof M, et al. Long-term results of 630 thoracoscopic sympathicotomies for primary hyperhidrosis: The Vienna experience. Eur J Surg Suppl. 1998;580:43-46.
Krasna MJ, Demmy TL, McKenna RJ, et al. Thoracoscopic sympathectomy: The U.S. experience. Eur J Surg Suppl. 1998;580:19-21.
Lin CC, Mo LR, Lee LS, et al. Thoracoscopic T2-sympathetic block by clipping--a better and reversible operation for treatment of hyperhidrosis palmaris: Experience with 326 cases. Eur J Surg Suppl. 1998;580:13-16.
Cohen Z, Levi I, Pinsk I, et al. Thoracoscopic upper thoracic sympathectomy for primary palmar hyperhidrosis -- the combined paediatric, adolescents and adult experience. Eur J Surg Suppl. 1998;580:5-8.
Lewis DR, Irvine CD, Smith FC, et al. Sympathetic skin response and patient satisfaction on long-term follow-up after thoracoscopic sympathectomy for hyperhidrosis. Eur J Vasc Endovasc Surg. 1998;15(3):239-243.
Gossot D, Toledo L, Fritsch S, et al. Thoracoscopic sympathectomy for upper limb hyperhidrosis: Looking for the right operation. Ann Thorac Surg. 1997;64(4):975-978.
Noppen M, Herregodts P, D'Haese J, et al. A simplified T2-T3 thoracoscopic sympathicolysis technique for the treatment of essential hyperhidrosis: Short-term results in 100 patients. J Laparoendosc Surg. 1996;6(3):151-159.
Graham AN, Owens WA, McGuigan JA. Assessment of outcome after thoracoscopic sympathectomy for hyperhidrosis in a specialized unit. J R Coll Surg Edinb. 1996;41(3):160-163.
Daniel TM. Thoracoscopic sympathectomy. Chest Surg Clin N Am. 1996;6(1):69-83.
Noppen M, Vincken W, Dhaese J, et al. Thoracoscopic sympathicolysis for essential hyperhidrosis: Immediate and one year follow-up results in 35 patients and review of the literature. Acta Clin Belg. 1996;51(4):244-253.
Levy I, Ariche A, Sebbag G, et al. Upper thoracic sympathectomy by thoracoscopic approach. A method of choice for the treatment of palmar hyperhidrosis. Ann Chir. 1995;49(9):858-862.
Hsu CP, Chen CY, Lin CT, et al. Video-assisted thoracoscopic T2 sympathectomy for hyperhidrosis palmaris. J Am Coll Surg 1994;179(1):59-64.
Adar R. Surgical treatment of palmar hyperhidrosis before thoracoscopy: Experience with 475 patients. Eur J Surg Suppl. 1994;572:9-11.
Friedel G, Linder A, Toomes H. Selective video-assisted thoracoscopic sympathectomy. Thorac Cardiovasc Surg. 1993;41(4):245-248.
Chou SH, Lee SH, Kao EL. Thoracic endoscopic T2-T3 sympathectomy in palmar hyperhidrosis: Experience of 112 cases. Surg Today. 1993;23(2):105-107.
Fox AD, Hands L, Collin J. The results of thoracoscopic sympathetic trunk transection for palmar hyperhidrosis and sympathetic ganglionectomy for axillary hyperhidrosis. Eur J Vasc Endovasc Surg. 1999;17(4):343-346.
Johnson JP, Obasi C, Hahn MS, et al. Endoscopic thoracic sympathectomy. J Neurosurg. 1999;91(1 Suppl):90-97.
Di Lorenzo N, Sica GS, Sileri P, et al. Thoracoscopic sympathectomy for vasospastic diseases. J Soc Laparoendosc Surg. 1998;2(3):249-253.
Yim AP, Liu HP, Lee TW, et al. 'Needlescopic' video-assisted thoracic surgery for palmar hyperhidrosis. Eur J Cardiothorac Surg. 2000;17(6):697-701.
Kargar S, Parizi FS. Thoracoscopic sympathectomy in causalgia. Ann Chir Gynaecol. 2001;90(3):193-194.
Ahmed O. Endoscopic thoracic sympathectomy for treating facial blushing. Evidence Centre Evidence Report. Clayton, VIC: Centre for Clinical Effectiveness (CCE); 2001.
Singh B, Shaik AS, Moodley J, et al. Limited thoracoscopic ganglionectomy for primary hyperhidrosis. S Afr J Surg. 2002;40(2):50-53.
De Giacomo T, Rendina EA, Venuta F, et al. Thoracoscopic sympathectomy for symptomatic arterial obstruction of the upper extremities. Ann Thorac Surg. 2002;74(3):885-8888.
Swedish Council on Technology Assessment in Health Care (SBU). Endoscopic transthoracic sympathectomy (ETS) - early assessment briefs (ALERT). Stockholm, Sweden: SBU; 2002.
Matthews BD, Bui HT, Harold KL, et al. Thoracoscopic sympathectomy for palmaris hyperhidrosis. South Med J. 2003;96(3):254-258.
Rzany B, Spinner DM. Interventions for localised excessive sweating (Protocol for Cochrane Review). Cochrane Database Syst Rev. 2000;(3):CD002953.
Fischbacher C. Sympathectomy for facial blushing. STEER: Succint and Timely Evaluated Evidence Reviews. Bazian, Ltd., eds. London, UK: Wessex Institute for Health Research and Development, University of Southampton; 2003;3(4).
Hashmonai M, Kopelman D, Assalia A. The treatment of primary palmar hyperhidrosis: A review. Surg Today. 2000;30(3):211-218.
Manchikanti L. The role of radiofrequency in the management of complex regional pain syndrome. Curr Rev Pain. 2000;4(6):437-444.
Kastler B, Michalakis D, Clair CH, et al. Stellate ganglion radiofrequency neurolysis under CT guidance. Preliminary study. JBR-BTR. 2001;84(5):191-194.
Mailis-Gagnon A, Furlan A. Sympathectomy for neuropathic pain. Cochrane Database Syst Rev. 2002;(1):CD002918.
Rizzo M, Balderson SS, Harpole DH, Levin LS. Thoracoscopic sympathectomy in the management of vasomotor disturbances and complex regional pain syndrome of the hand. Orthopedics. 2004;27(1):49-52.
Kumagai K, Kawase H, Kawanishi M. Health-related quality of life after thoracoscopic sympathectomy for palmar hyperhidrosis. Ann Thorac Surg. 2005;80:461-466.
Kwong KF, Cooper LB, Bennett LA, et al. Clinical experience in 397 consecutive thoracoscopic sympathectomies. Ann Thorac Surg. 2005;80:1063-1066.
Lee AD, Agarwal S, Sadhu D. A 7-year experience with thoracoscopic sympathectomy for critical upper limb ischemia. World J Surg. 2006;30(9):1644-1647.
Thune TH, Ladegaard L, Licht PB. Thoracoscopic sympathectomy for Raynaud's phenomenon -- a long term follow-up study. Eur J Vasc Endovasc Surg. 2006;32(2):198-202.
Malmivaara A, Kuukasjarvi P, Autti-Ramo I, et al. Effectiveness and safety of endoscopic thoracic sympathectomy [summary]. FinOHTA Report No. 26. Helsinki, Finland: Finnish Office for Health Care Technology Assessment (FinOHTA); 2005.
Tomaszewski S, Szyca R, Jasinski A, Leksowski K. Bilateral posterior thoracoscopic splanchnicectomy in a face-down position in the management of chronic pancreatic pain. Pol Merkur Lekarski. 2007;22(131):399-401.
Kang CM, Lee HY, Yang HJ, et al. Bilateral thoracoscopic splanchnicectomy with sympathectomy for managing abdominal pain in cancer patients. Am J Surg. 2007;194(1):23-29.
Krasna MJ. Thoracoscopic sympathectomy: A standardized approach to therapy for hyperhidrosis. Ann Thorac Surg. 2008;85(2):S764-S767.
Malmivaara A, Kuukasjärvi P, Autti-Ramo I, et al. Effectiveness and safety of endoscopic thoracic sympathectomy for excessive sweating and facial blushing: A systematic review. Int J Technol Assess Health Care. 2007;23(1):54-62.
Henteleff HJ, Kalavrouziotis D. Evidence-based review of the surgical management of hyperhidrosis. Thorac Surg Clin. 2008;18(2):209-216.
Jeganathan R, Jordan S, Jones M, et al. Bilateral thoracoscopic sympathectomy: Results and long-term follow-up. Interact Cardiovasc Thorac Surg. 2008;7(1):67-70.
Steiner Z, Cohen Z, Kleiner O, et al. Do children tolerate thoracoscopic sympathectomy better than adults? Pediatr Surg Int. 2008;24(3):343-347.
Ambrogi V, Campione E, Mineo D, et al. Bilateral thoracoscopic T2 to T3 sympathectomy versus botulinum injection in palmar hyperhidrosis. Ann Thorac Surg. 2009;88(1):238-245.
Coelho Mde S, Silva RF, Mezzalira G, et al. T3T4 endoscopic sympathetic blockade versus T3T4 video thoracoscopic sympathectomy in the treatment of axillary hyperhidrosis. Ann Thorac Surg. 2009 Dec;88(6):1780-1785.
Watt A, Cameron AL, Maddern GJ. Evidence Essential: Endoscopic thoracic sympathectomy. ASERNIP-S Report No. 71 Adelaide, SA: Australian Safety & Efficacy Register of New Interventional Procedures – Surgical (ASERNIP-S); August 2009.
Awad MS, Elzeftawy A, Mansour S, Elshelfa W. One stage bilateral endoscopic sympathectomy under local anesthesia: Is a valid, and safe procedure for treatment of palmer hyperhidrosis? J Minim Access Surg. 2010;6(1):11-15.
Bejarano B, Manrique M. Thoracoscopic sympathectomy: A literature review. Neurocirugia (Astur). 2010;21(1):5-13.
Straube S, Derry S, Moore RA, McQuay HJ. Cervico-thoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome. Cochrane Database Syst Rev. 2010;(7):CD002918.
Deng B, Tan QY, Jiang YG, et al. Optimization of sympathectomy to treat palmar hyperhidrosis: The systematic review and meta-analysis of studies published during the past decade. Surg Endosc. 2011;25(6):1893-1901.
Coveliers H, Atif S, Rauwerda J, Wisselink W. Endoscopic thoracic sympathectomy: Long-term results for treatment of upper limb hyperhidrosis and facial blushing. Acta Chir Belg. 2011;111(5):293-297.
Baumgartner FJ, Reyes M, Sarkisyan GG, et al. Thoracoscopic sympathicotomy for disabling palmar hyperhidrosis: A prospective randomized comparison between two levels. Ann Thorac Surg. 2011;92(6):2015-2019.
Stefaniak T, Cwigon M, Łaski D. In the search for the treatment of compensatory sweating. ScientificWorldJournal. 2012;2012:134547.
Heidemann E, Licht PB. A comparative study of thoracoscopic sympathicotomy versus local surgical treatment for axillary hyperhidrosis. Ann Thorac Surg. 2013;95(1):264-268.
Ibrahim M, Menna C, Andreetti C, et al. Two-stage unilateral versus one-stage bilateral single-port sympathectomy for palmar and axillary hyperhidrosis. Interact Cardiovasc Thorac Surg. 2013;16(6):834-838.
Hofferberth SC, Cecchin F, Loberman D, Fynn-Thompson F. Left thoracoscopic sympathectomy for cardiac denervation in patients with life-threatening ventricular arrhythmias. J Thorac Cardiovasc Surg. 2014;147(1):404-409.
De Ferrari GM, Schwartz PJ. Left cardiac sympathetic denervation in patients with heart failure: A new indication for an old intervention? J Cardiovasc Transl Res. 2014;7(3):338-346.
Colucci WS. Management of refractory heart failure. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed January 2015.
Costello JP, Wilson JK, Louis C, et al. Surgical cardiac denervation therapy for treatment of congenital ion channelopathies in pediatric patients: A contemporary, single institutional experience. World J Pediatr Congenit Heart Surg. 2015;6(1):33-38.
Ravari H, Rajabnejad A. Unilateral sympathectomy for primary palmar hyperhidrosis. Thorac Cardiovasc Surg. 2015 Jan 20 [Epub ahead of print].
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