Hyperhidrosis
Hyperhidrosis is the medical term for
excessive sweating. There are many medical reasons for excessive
sweating. When caused by another medical problem, we use the term
secondary hyperhidrosis. When there is not an underlying medical
problem causing the sweating we use the term primary hyperhidrosis.
Many people have experienced excessive
sweating at some point of time in their lives, but when excessive sweating
interferes with daily function it is considered a medical problem.
You will be asked to complete the attached
questionnaire - Hyperhidrosis Disease Severity Scale at each visit.
This is the standard form that quantifies your severity and medical
necessity.
Topical Agents
For most people, sweating is controlled
with over the counter antiperspirants. For many other people a
prescription strength solution can help to control sweating. The
most commonly used of theses is an aluminum chloride solution called
DRYSOL. Most insurance companies require a trial of this medication
prior to approving BOTOX injections for hyperhidrosis.
BOTOX
More recently, BOTOX has been used for
hyperhidrosis. BOTOX is Botulinum Toxin A. This is injected
into the skin using a needle. BOTOX® is FDA-approved
for severe underarm sweating that is inadequately managed with topical
agents. BOTOX® helps control this condition by temporarily
blocking the chemical signals from the nerves that stimulate the sweat
glands. When the sweat glands don't receive chemical signals, the severe
sweating stops.
Iontophoresis
This procedure involves sending a small electrical current to the surface
of the affected area while it is submerged in water. In general, treatments
must be repeated 3-4 times per week. The procedure can be done at home
using a home device. Although this procedure can be used for treating
severe underarm sweating, it is usually more useful for controlling
sweating in other areas of the body, such as the hands and feet.
Surgery
A variety of surgical approaches have been used to treat severe sweating,
but they are usually reserved for the most severe cases that do not
respond to other treatments. One of the most common types of surgery
used today for this condition is called endoscopic thoracic sympathectomy
(ETS). With ETS, the patient is put to sleep with general anesthesia
and then the surgeon attempts to interrupt the transmission of nerve
signals between the spinal column and sweat glands in the affected area.
This procedure requires special training, and may result in unwanted
increased sweating from other areas of the bodycalled "compensatory
sweating." Other types of surgery sometimes used for severe underarm
sweating include liposuction and removal of the sweat glands under the
armpits.
Alternative therapy
Herbal remedies such as sage tea or sage tablets, chamomile, valerian
root, and St. John's wort, as well as biofeedback, acupuncture, hypnosis,
and relaxation techniques, are sometimes suggested as treatments for
excessive sweating. However, there is little research at this time to
indicate the effectiveness of such treatments.
How effective is BOTOX therapy?
Botox therapy appears to be very effective
for most patients. In a clinical study 91% of BOTOX®
patients achieved at least a 50% reduction in axillary sweating at 4
weeks postinjection. You should notice a significant reduction
in underarm sweating
within 4 weeks of your first treatment. There is a possibility that
some sweat glands
may be missed, and you may continue to experience some sweating from
the untreated areas. In this case a touch up can be done to these
areas. Prior to your treatment a starch iodine test can be done
to determine the exact areas where you need injections. This test
enhances your probability for success. The results are not permanent.
In a key clinical study, half of the patients had a treatment duration
of at least 201 days or 6.7 months.
It is not a cure; your symptoms will return gradually, and you will
know when the time is right for another treatment. If you decide not
to have further treatment, there will be no lasting change in the treated
areas. The effects of BOTOX® treatment will gradually wear
off, and your underarm sweating will resume.
Insurance Coverage
Most insurances do not cover BOTOX injections
without prior authorization and proof of medical necessity letter.
BOTOX has developed a program to help determine your insurance coverage
for this procedure. Without insurance coverage, this is a very
expensive procedure. If you would like to request your insurance
to cover your BOTOX injections, please complete the following forms.
We will forward them to the BOTOX Advantage program on your behalf.
We also recommend that you contact your insurance company directly to
determine their policy on BOTOX injections.
To discuss this with your insurance company
you will need to provide them with the following codes.
ICD9 Hyperhidrosis, focal
705.2. For more specification if needed, Primary 705.21, Secondary
705.22
CPT for BOTOX injection
64650 Both Axillae, 64999 Hands or Feet, 64653 Other areas
J0585 Botox A per unit - Average
100 units for axillae BL.
www.botoxreimbursement.us
Toll-free fax: 877.530.6680
Toll-free phone: 800.530.6680
Hours: 9am 8pm ET (Mon Fri)
BOTOX ADVANTAGE®
Program
1-800-530-6680
(phone) " 1-877-530-6680 (fax) "
www.BOTOX.com
INSURANCE
RESEARCH REQUEST FORM
*please print
or type
REQUIRED: Do
you have your patients written consent to release patient
identifiable information for the purpose of conducting insurance research?
|
|
|
Patient Information |
Patient Name:
M / F (please
circle)
Date of Birth: Social Security
Number:
Address:
City, State, Zip:
Phone: Fax: |
| Treatment
Information |
Diagnosis 1: ___________
CPT code 1: ___________
Diagnosis 2: ___________ (if applicable) CPT code 2: ___________(if applicable)
*The Hotline cannot verify
benefits without a diagnosis code.
EMG
code: ___________ (if
applicable)
Date
of Service (if scheduled): _________________________________________
*Please note, insurer
may take up to 3 weeks to process prior authorization.
Place of Service: q
Physicians Office q Hosp. Outpt. q Hosp. Inpt.
q
ASC q
SNF q
Other # of Units or Vials:
Injection Sites: |
| Prescribing
Physician Information |
Physician Name:
Tax ID#: Specialty:
Facility Name:
Office Contact Name:
Address:
City, State, Zip:
Phone: Fax:
Email: |
| Insurance
Information (Primary Insurer)
q
Commercial q Medicare
q
Medicaid q
Automobile
q
Workers Compensation
q
CHAMPUS/TRICARE
q
Other: _________________ |
Name of Insurance Company:
Address:
City, State, Zip:
Phone: Fax:
Policy Holders Name: Relationship
to Patient:
Date of Birth: Social Security
#:
Policy/Claim #: Group/Plan #:
Employers Name:
Physicians Provider # (Required for Medicare or Medicaid):
Physicians participation
with the insurer? q
Participating q
Non-participating |
| Insurance
Information (Secondary Insurer)
q
Commercial q Medicare
q
Medicaid q
Automobile
q
Workers Compensation
q
CHAMPUS/TRICARE
q
Other: _________________ |
Name of Insurance Company:
Address:
City, State, Zip:
Phone: Fax:
Policy Holders Name: Relationship
to Patient:
Date of Birth: Social Security
#:
Policy/Claim #: Group/Plan #:
Employers Name:
Physicians Provider # (Required for Medicare or Medicaid):
Physicians participation
with the insurer? q
Participating q
Non-participating |
The BOTOX ADVANTAGE®
Program is provided as an information service only. While every
attempt is made to provide up-to-date information, Allergan does not
ensure the accuracy of the information provided. Since third-party
reimbursement is affected by many factors, Allergan makes no representation
or guarantee that a patient will be successful in obtaining insurance
reimbursement or any other payment.
THE BOTOX
ADVANTAGE® PROGRAMS
PATIENT Authorization for Release
of Information
FOR Insurance, reimbursement, and
coverage assistance
State and federal laws protect
the confidentiality of your medical information. When you sign
this form, you are giving your physician permission to release confidential
medical information to the BOTOX ADVANTAGE® Program, including Allergan, to review
and assess your insurance, reimbursement, and coverage for BOTOX®
and BOTOX® related procedures. You are also giving
the BOTOX ADVANTAGE® Program, including Allergan and its
employees, permission to release confidential medical information to
insurance companies that we contact on your behalf, for this purpose.
Such information may include your name, age, sex, medical diagnosis,
insurance identifiers, employers, or medical providers you identify.
Please sign this form after
reading the statement below:
I, _______________________,
authorize my physician to release confidential medical information,
on my behalf to the BOTOX ADVANTAGE® Program, including Allergan and its
employees in order to evaluate my insurance, reimbursement, and coverage
for BOTOX®. The BOTOX ADVANTAGE®
Program also may contact my employer and/or medical provider(s), specifically
____________________________, to complete my request. I verify
that I have provided my medical information voluntarily and that the
BOTOX ADVANTAGE® Program will not release this oral
or written information without my consent. In addition, I understand
that the BOTOX ADVANTAGE® Program cannot guarantee that the
third parties contacted will keep my information confidential.
I also understand that the third parties the BOTOX ADVANTAGE®
Program contacts may reside in states other than my own and may have
a different set of confidentiality laws to follow. This authorization
will remain in effect until I no longer need assistance from the BOTOX
ADVANTAGE® Program or until I revoke the authorization
by calling or writing the BOTOX ADVANTAGE® Program.
________________________________________ _______________________
Signature Date
Phone:__________________________________
(area code)
| Please
fax the signed form to: 877-530-6680
or return the signed form to:
The BOTOX
ADVANTAGE® Program
PO Box 13185
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If you have questions,
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