Prior Authorization Review Panel MCO Policy Submission A ......into three regions: cervical (neck), thoracic (chest) and lumbar (lower back). Sympathectomy is commonly targeted to

Prior Authorization Review Panel MCOPolicy Submission

A separate copy of this form must accompany each policy submitted for review.Policies submitted without this form will not be considered for review.

Plan: Aetna Better Health Submission Date: 11/01/2018

Policy Number: 0310 Effective Date: Revision Date:

Policy Name: Thoracoscopic Sympathectomy

Type of Submission – Check all that apply: New Policy Revised Policy

Annual Review – No Revisions* *All revisions to the policy must be highlighted using track changes throughout the document. Please provide any clarifying information for the policy below:

CPB 0310 Thoracoscopic Sympathectomy

Clinical content was last revised on 06/01/2016. No additionalnon-clinical updates were made by Corporate since the last PARP submission, as documented below.

Revision and Update History since last PARP submission: 07/31/2018 - Tentative next scheduled review date by Corporate, no updates.

Name of Authorized Individual (Please type or print):

Dr. Bernard Lewin, M.D.

Signature of Authorized Individual:

www.aetnabetterhealth.com/pennsylvania Annual 11/01/2018

http://www.aetnabetterhealth.com/pennsylvania

http://aetnet.aetna.com/mpa/cpb/300_399/0310.html 10/24/2018

Thoracoscopic Sympathectomy - Medical Clinical Policy Bulletins | Aetna Page 1 of 19

-->

(https://www.aetna.com/)

Thoracoscopic Sympathectomy

Policy His tory

Last Review

07/31/2018

Effective: 12/01/1998

Next

Review: 03/14/2019

Review History

Definitions

A dditiona l In form at ion

Clinical Policy

Bulletin Notes

Number: 0310

*Please see amendment for Pennsylvania Medicaid at the end of this CPB.

Policy

I. Aetna considers thoracoscopic sympathectomy

medically necessary for any of the following conditions:

A. Causalgia; or

B. Catecholaminergic polymorphic ventricular tachycardia

(CPVT), in persons who remain symptomatic despite

maximal medical therapy; or

C. Long QT syndrome, in persons who have failed medical

therapy and have frequent shocks with an ICD despite

medications; or

D. Raynaud's disease; or

E. Shoulder-hand syndrome; or

F. Some types of visceral pain (e.g., chronic pancreatic

pain and cancer-derived visceral abdominal pain); or

G. Vascular occlusive disease; or

H. Intractable, disabling axillary or palmar primary

hyperhidrosis (excessive sweating) when all of the

following are met (see

also CPB 0504 - Hyperhydrosis (../500_599/0504.html))

https://www.aetna.com/

http://aetnet.aetna.com/mpa/cpb/300_399/0310.html



▪ Iontophoresis or electrophoresis, (e.g., Drionic®

device) is ineffective

(see CPB 0229 - Iontophoresis (../200_299/0229.html))

(a trial of botulinum toxin can be substituted for

iontophoresis in persons with predominantly axillary

hyperhidrosis --

CPB 0113 - Botulinum Toxin

see (../100_199/0113.html) );

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.

II. 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.

III. Aetna considers thoracoscopic sympathectomy

experimental and investigational for all other

indications (e.g., acne vulgaris, craniofacial or plantar

hyperhidrosis) becasue its effectiveness for indications

other than the ones listed above has not been

established.

IV. 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.

See also CPB 0031 - Cosmetic Surgery (../1_99/0031.html).

Background

Sympathectomy is a surgical procedure that involves

cauterizing (cutting and sealing) a portion of the sympathetic

nerve chain that runs down the inside of the chest cavity. This

operation permanently interrupts the nerve signal that is

causing the body to sweat excessively and can be performed

in either of the two sympathetic trunks. Each trunk is divided

into three regions: cervical (neck), thoracic (chest) and lumbar

(lower back). Sympathectomy is commonly targeted to the

upper thoracic region.

Endoscopic thoracic sympathectomy (ETS) is performed by

inserting a scope with a camera into the chest via a small

incision under the axilla. The lung is temporarily collapsed so

the surgeon can cut or otherwise destroy the nerve paths

associated with the overactive sweat glands. The same

procedure is repeated on the other side of the body. Side

effects, especially compensatory hyperhidrosis in other parts

of the body, may reduce long term satisfaction with this

procedure. Sweating returns in approximately 50% of patients.

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.

Thoracoscopic Sympathectomy for the Treatment of Acne Vulgaris:

Kaplan et al (2014) examined the therapeutic effect of

thoracoscopic sympathicotomy performed at their clinic for

facial/scalp hyperhidrosis or blushing on coincidental facial

acne vulgaris based on previous reports indicating an

association between the sympathetic nerve stimulus, epithelial

melanocyte system and sebogenesis. The possible

therapeutic effects of sympathicotomy on facial acne vulgaris

were analyzed in a study design of retrospective review with

prospective collection of the data from March 2005 to March

2013. A total of 42 patients were operated on at the authors’

clinic due to facial/scalp hyperhidrosis or blushing and 30 of

these also had facial acne vulgaris. However, none harbored

a systemic co-morbidity. Patients' medical history indicated

that they had used several medical therapies including topical

or systemic anti-biotherapies to treat their acne for several

years but this had met with limited success and the treatment

was stopped in all patients an average of 8 ± 2.4 months prior

to the operations. Furthermore, the patients with acne vulgaris

also underwent a thoracoscopic sympathicotomy procedure at

the second costal head (R2) for hyperhidrosis or blushing. All

30 patients showed marked improvement of their acne grade

at the 1st post-operative month (p < 0.01). The authors

concluded that in this study, the patients' facial acne vulgaris

grade significantly improved after undergoing a

sympathicotomy. This can be explained by the possible effect




the nervous system had on the epithelial melanocyte system

and sebogenesis. However, these researchers stated that

prospective studies with an increased number of patients are

needed to verify these findings.

Furthermore, an UpToDate review on “Treatment of acne

vulgaris” (Graber, 2016) does not mention thoracoscopic

sympathectomy as a therapeutic option.

Trans-Umbilical Thoracic Sympathectomy for the Treatment of Palmar Hyperhidrosis:

Zhu et al (2016) noted that thoracic sympathectomy is

considered as the most effective method to treat palmar

hyperhidrosis (PH). These investigators reported their

experience of trans-umbilical thoracic sympathectomy with an

ultra-thin flexible endoscope for PH in a series of 148 patients

with up to 4 years of follow-up. A prospective database was

used in this retrospective analysis of 148 patients (61 males,

87 females, with a mean age of 21.3 years) with PH who were

operated on by the same surgeon in a single institution from

April 2010 to March 2014. All procedures were performed

under general anesthesia involving intubation with a double-

lumen endotracheal tube. Demographic, post-operative and

long-term data of patients were recorded and statistical

analyses were performed. All patients were followed-up at

least 6 months post-procedure through clinic visits or

telephone/e-mail interviews. The procedure was performed

successfully in 148 of the 150 patients; 2 patients had to be

converted to conventional thoracoscopic procedure because of

severe pleural adhesions. The mean operating time was 43

minutes (ranging from 39 to 107) and the mean post-operative

length of stay was 1 day (range of 1 to 4). All patients were

interviewed 6 to 48 months after surgery and no diaphragmatic

hernia or syndrome was observed. The rate of resolution of

PH and axillary hyperhidrosis was 98 and 74.6 %, respectively.

Compensatory sweating was reported in 22.3 % of patients.

Almost all of the patients were satisfied with the surgical




results and the cosmetic outcome of the incision. The authors

concluded that these preliminary findings suggested that trans-

umbilical thoracic sympathectomy was a safe and effective

alternative to the conventional approach. This technique

avoided the chronic pain and chest wall paresthesia that are

associated with the chest incision. In addition, this novel

procedure afforded maximum cosmetic benefits. The main

drawbacks of this study were: (i) the lack of a comparison

group and (ii) it was a single-center study and the

procedure was performed by a single surgeon.

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

Code Code Description

CPT codes covered if selection criteria are met:

32664 Thoracoscopy, surgical; with thoracic

sympathectomy

Other CPT codes related to the CPB:

64650 Chemodenervation of eccrine glands; both

axillae

64804 Sympathectomy, cervicothoracic

97033 Application of a modality to one or more areas;

iontophoresis, each 15 minutes

Other HCPCS codes related to the CPB:

J0585 Botulinum toxin type A, per unit

J0587 Botulinum toxin type B, per 100 units

ICD-10 codes covered if selection criteria are met: G56.40 -

G56.42

Causalgia of upper limb




Code Code Description

G57.70 -

G57.72

Causalgia of lower limb

I45.81 Long QT syndrome [in persons who have failed

medical therapy and have frequency ICD

shocks despite medications]

I47.2 Ventricular tachycardia [catecholaminergic

polymorphic, in persons who remain

symptomatic despite maximal medical therapy]

I73.00 -

I73.01

Raynaud's syndrome

L74.510,

L74.512,

L74.519

L74.52

Primary and secondary focal hyperhidrosis

[intractable, disabling - see criteria]

ICD-10 codes not covered for indications listed in the CPB:

I49.01 -

I49.02

Ventricular fibrillation and flutter

I47.2 Ventricular tachycardia

I47.9 Paroxysmal tachycardia, unspecified

I50.1 -

I50.9

Heart failure

L70.0 Acne vulgaris

L74.511 Primary focal hyperhidrosis, face

L74.513 Primary focal hyperhidrosis, soles

R23.2 Flushing

The above policy is based on the following




references:

1. 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.

2. Krasna MJ, Demmy TL, McKenna RJ, et al.

Thoracoscopic sympathectomy: The U.S. experience.

Eur J Surg Suppl. 1998;580:19-21.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. Daniel TM. Thoracoscopic sympathectomy. Chest Surg

Clin N Am. 1996;6(1):69-83.




10. 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.

11. 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.

12. Ahn SS, Machleder HI, Concepcion B, et al.

Thoracoscopic cervicodorsal sympathectomy:

Preliminary results. J Vasc Surg. 1994;20(4):511-517.

13. 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.

14. Adar R. Surgical treatment of palmar hyperhidrosis

before thoracoscopy: Experience with 475 patients.

Eur J Surg Suppl. 1994;572:9-11.

15. Friedel G, Linder A, Toomes H. Selective video-assisted

thoracoscopic sympathectomy. Thorac Cardiovasc

Surg. 1993;41(4):245-248.

16. 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.

17. 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.

18. Johnson JP, Obasi C, Hahn MS, et al. Endoscopic

thoracic sympathectomy. J Neurosurg. 1999;91(1

Suppl):90-97.

19. Di Lorenzo N, Sica GS, Sileri P, et al. Thoracoscopic

sympathectomy for vasospastic diseases. J Soc

Laparoendosc Surg. 1998;2(3):249-253.




20. 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.

21. Kargar S, Parizi FS. Thoracoscopic sympathectomy in

causalgia. Ann Chir Gynaecol. 2001;90(3):193-194.

22. Ahmed O. Endoscopic thoracic sympathectomy for

treating facial blushing. Evidence Centre Evidence

Report. Clayton, VIC: Centre for Clinical Effectiveness

(CCE); 2001.

23. Singh B, Shaik AS, Moodley J, et al. Limited

thoracoscopic ganglionectomy for primary

hyperhidrosis. S Afr J Surg. 2002;40(2):50-53.

24. 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.

25. Swedish Council on Technology Assessment in Health

Care (SBU). Endoscopic transthoracic sympathectomy

(ETS) - early assessment briefs (ALERT). Stockholm,

Sweden: SBU; 2002.

26. Matthews BD, Bui HT, Harold KL, et al. Thoracoscopic

sympathectomy for palmaris hyperhidrosis. South

Med J. 2003;96(3):254-258.

27. Rzany B, Spinner DM. Interventions for localised

excessive sweating (Protocol for Cochrane Review).

Cochrane Database Syst Rev. 2000;(3):CD002953.

28. 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).

29. Hashmonai M, Kopelman D, Assalia A. The treatment

of primary palmar hyperhidrosis: A review. Surg

Today. 2000;30(3):211-218.

30. Manchikanti L. The role of radiofrequency in the

management of complex regional pain syndrome. Curr

Rev Pain. 2000;4(6):437-444.




31. Kastler B, Michalakis D, Clair CH, et al. Stellate ganglion

radiofrequency neurolysis under CT guidance.

Preliminary study. JBR-BTR. 2001;84(5):191-194.

32. Mailis-Gagnon A, Furlan A. Sympathectomy for

neuropathic pain. Cochrane Database Syst Rev. 2002;

(1):CD002918.

33. 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.

34. Kumagai K, Kawase H, Kawanishi M. Health-related

quality of life after thoracoscopic sympathectomy for

palmar hyperhidrosis. Ann Thorac Surg. 2005;80:461

466.

35. Kwong KF, Cooper LB, Bennett LA, et al. Clinical

experience in 397 consecutive thoracoscopic

sympathectomies. Ann Thorac Surg. 2005;80:1063

1066.

36. 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.

37. 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.

38. 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.

39. 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.

40. 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.

41. Krasna MJ. Thoracoscopic sympathectomy: A

standardized approach to therapy for hyperhidrosis.

Ann Thorac Surg. 2008;85(2):S764-S767.

42. 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.

43. Henteleff HJ, Kalavrouziotis D. Evidence-based review

of the surgical management of hyperhidrosis. Thorac

Surg Clin. 2008;18(2):209-216.

44. Smith. Idiopathic hyperhidrosis. UpToDate [online

serial]. Waltham, MA: UpToDate; 2008.

45. 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.

46. Steiner Z, Cohen Z, Kleiner O, et al. Do children

tolerate thoracoscopic sympathectomy better than

adults? Pediatr Surg Int. 2008;24(3):343-347.

47. 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.

48. 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.

49. 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.




50. 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.

51. Bejarano B, Manrique M. Thoracoscopic

sympathectomy: A literature review. Neurocirugia

(Astur). 2010;21(1):5-13.

52. 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.

53. 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.

54. 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.

55. 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.

56. Stefaniak T, Cwigon M, Łaski D. In the search for the

treatment of compensatory sweating.

ScientificWorldJournal. 2012;2012:134547.

57. 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.

58. 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.




59. 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.

60. 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.

61. Colucci WS. Management of refractory heart failure.

UpToDate [online serial]. Waltham, MA: UpToDate;

reviewed January 2015.

62. 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.

63. Ravari H, Rajabnejad A. Unilateral sympathectomy for

primary palmar hyperhidrosis. Thorac Cardiovasc

Surg. 2015;63(8):723-726.

64. Kaplan T, Gunduz O, Oznur B, Han S. Could

thoracoscopic sympathicotomy for hyperhidrosis also

improve acne vulgaris? Kardiochir Torakochirurgia Pol.

2014;11(3):264-267.

65. Graber E. Treatment of acne vulgaris. UpToDate

[online serial]. Waltham, MA: UpToDate; reviewed

January 2016.

66. Zhu LH, Chen W, Chen L, et al. Transumbilical thoracic

sympathectomy: A single-centre experience of 148

cases with up to 4 years of follow-up. Eur J

Cardiothorac Surg. 2016;49 Suppl 1:i79-i83.

67. Zhang W, Yu D, Jiang H, et al. Video-assisted

thoracoscopic sympathectomy for palmar

hyperhidrosis: A meta-analysis of randomized

controlled trials. PLoS One. 2016;11(5):e0155184.

68. Laje P, Rhodes K, Magee L, Klarich MK. Thoracoscopic

bilateral T3 sympathectomy for primary focal




hyperhidrosis in children. J Pediatr Surg. 2017;52

(2):313-316.



Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan

benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,

general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care

services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors

in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely

responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is

subject to change.

Copyright © 2001-2018 Aetna Inc.



AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0310 Thoracoscopic Sympathectomy

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania Annual 11/01/2018

http://www.aetnabetterhealth.com/pennsylvania

Documents

Prior Authorization Review Panel MCO Policy Submission A ......into three regions: cervical (neck), thoracic (chest) and lumbar (lower back). Sympathectomy is commonly targeted to