Thoracoscopic Sympathectomy

Coverage Summary

Scope: This policy defines Aetna's coverage positions for thoracoscopic sympathectomy (endoscopic thoracic sympathectomy/ETS). Aetna's overall stance is mixed: thoracoscopic sympathectomy is considered medically necessary for specified indications (including causalgia, selected arrhythmia indications such as CPVT and long QT syndrome when medical therapy/ICD management has failed or is not tolerated, Raynaud's disease, shoulder-hand syndrome, some visceral pain, VT/VF storm refractory to standard therapies, vascular occlusive disease, and intractable disabling axillary or palmar primary hyperhidrosis when conservative measures have failed), is experimental/investigational for other indications (e.g., acne vulgaris, craniofacial or plantar hyperhidrosis, and left thoracoscopic sympathectomy for cardiac denervation in persons with heart failure), and is cosmetic when used for excessive spontaneous facial blushing.

High-level context and evidence themes: ETS/ thoracoscopic sympathectomy has been reported to be effective in reducing palmar and some facial hyperhidrosis in multiple series, but the evidence base is limited by variable and generally low methodological quality, inconsistent outcome reporting, and few long-term controlled trials. Compensatory hyperhidrosis and other complications are common and can be disabling. Emerging, small-series data suggest that left cardiac sympathetic denervation (video-assisted thoracoscopic cardiac denervation) can reduce arrhythmic burden and ICD shocks in selected patients with life-threatening ventricular arrhythmias (including congenital channelopathies and refractory electrical storm), but these findings require further validation in larger, well-designed studies.

Listed medically necessary indications9

Experimental/investigational exclusions listed2

Cosmetic exclusion (facial blushing)1

Select references cited~20

Number of literature references listedReferences: 83+

Medical Necessity

Aetna considers thoracoscopic sympathectomy medically necessary for any of the following conditions:

Medical Necessity - indications

Causalgia
Catecholaminergic polymorphic ventricular tachycardia (CPVT), in persons who remain symptomatic despite maximal medical therapy
Long QT syndrome, in persons who have failed medical therapy and have frequent shocks with an implantable cardioverter defibrillator (ICD) despite medications
Raynaud's disease

Experimental / Not Medically Necessary

Experimental and Investigational (Not Medically Necessary)

Considered experimental and investigational because effectiveness has not been established:

Experimental and Investigational exclusions

Other indications not listed as necessary: Thoracoscopic sympathectomy for all other indications (e.g., acne vulgaris, craniofacial or plantar hyperhidrosis) other than the ones listed above
Left thoracoscopic sympathectomy for heart failure: Left thoracoscopic sympathectomy for cardiac denervation in persons with heart failure

ref

Cosmetic (Not Covered)

Considered cosmetic when indication is:

Coding

Covered CPT codes if selection criteria are metCPTCovered

32664

Thoracoscopy, surgical; with thoracic sympathectomy

Other related CPT codes (neutral/listed for reference)CPT

64650	Chemodenervation of eccrine glands; both axillae
64804	Sympathectomy, cervicothoracic
93650	Intracardiac catheter ablation procedures (range 93650-93657)
97033	Application of a modality to one or more areas; iontophoresis, each 15 minutes

Other related HCPCS/J-codesHCPCS

J0585	Botulinum toxin type A, per unit
J0587	Botulinum toxin type B, per 100 units

ICD-10 codes covered if selection criteria are metICD-10Covered

G56.40	Causalgia of upper limb
G56.41	Causalgia of upper limb
G56.42	Causalgia of upper limb
G57.70	Causalgia of lower limb
G57.71	Causalgia of lower limb
G57.72	Causalgia of lower limb
I45.81	Long QT syndrome [in persons who have failed medical therapy and have frequent ICD shocks despite medications]
I47.2	Ventricular tachycardia
I49.01	Ventricular fibrillation
I73.00	Raynaud's syndrome

1–10 of 15

1/2

ICD-10 codes not covered for indications listed in the CPBICD-10Not Covered

I50.1	Heart failure
I50.2	Heart failure
I50.3	Heart failure
I50.4	Heart failure
I50.9	Heart failure, unspecified
L70.0	Acne vulgaris
L74.511	Primary focal hyperhidrosis, face
L74.513	Primary focal hyperhidrosis, soles
R23.2	Flushing

Provider Actions / Documentation Requirements

Documentation Required

Hyperhidrosis conservative therapy trial documentation

For intractable, disabling axillary or palmar primary hyperhidrosis, document trials of iontophoresis or electrophoresis (or a trial of botulinum toxin for predominantly axillary hyperhidrosis), failure of topical aluminum chloride/other extra‑strength antiperspirants or severe rash from them, significant disruption of professional and/or social life due to excessive sweating, and intolerance or nonresponse to pharmacotherapy when applicable.

Trial of iontophoresis or electrophoresis (e.g., Drionic® device) — or trial of botulinum toxin substituted for iontophoresis if predominantly axillary hyperhidrosis
Failure of topical aluminum chloride or other extra‑strength antiperspirants, or development of a severe rash from them
Significant disruption of professional and/or social life because of excessive sweating
Unresponsive to or unable to tolerate pharmacotherapy prescribed for excessive sweating (e.g., anticholinergics, beta‑blockers, benzodiazepines) when sweating is episodic

Background / Evidence Summary

Background (technique): Endoscopic thoracic sympathectomy (ETS) is performed by inserting a thoracoscopic scope via small incisions (typically under the axilla) with temporary lung collapse to permit transection, cauterization, clipping or ganglionectomy of portions of the upper thoracic sympathetic chain (commonly targeted T1–T4 levels) to interrupt sympathetic signals driving excessive sweating or to achieve cardiac sympathetic denervation.

Summary of evidence quality and outcomes: The literature is limited and heterogeneous with many studies of poor methodological quality and inconsistent outcome reporting. Systematic assessments (FinOHTA; Malmivaara et al.) and reviews have concluded the evidence for ETS effectiveness is weak and that studies are difficult to synthesize due to poor reporting. For palmar hyperhidrosis, some series and meta-analyses report high initial resolution rates (reports of palmar hyperhidrosis resolution up to 98% in selected series), and ETS is often effective when topical therapies, iontophoresis, and botulinum toxin have failed. However, reported rates of compensatory hyperhidrosis are substantial (observed in approximately 50% or more of patients in multiple series, and causing significant disability in about 3–15% of those affected), acute postoperative complications (including pneumothorax/hemothorax and Horner's syndrome) have been reported (acute complications up to about 10% in some series), and long-term satisfaction can be reduced by these adverse effects.

Cardiac denervation evidence: Emerging small-series reports of video-assisted thoracoscopic left cardiac sympathetic denervation for life-threatening ventricular arrhythmias (including congenital LQTS and CPVT and refractory electrical storm) show promising but preliminary results — for example, a single-institution series reported 73% of patients with a marked reduction in arrhythmia burden and 55% becoming arrhythmia-free after LCSD (Hofferberth et al., 2014), and other small series/observational reports show reduced ICD shocks and VT recurrence in selected refractory patients — yet these data are from limited cohorts with short follow-up and require validation in larger, well-designed studies.

OpenPayer