Getting Heavy-Sweating Treatment Covered: Prior Authorization and Appeals

If over-the-counter antiperspirants haven’t controlled heavy sweating, a dermatologist may suggest prescription options, injections or a procedure. Some of these cost a lot without insurance, and insurers often ask for proof before they’ll pay. This guide walks through building that proof and appealing a denial.

1. Read your plan’s policy first

The International Hyperhidrosis Society¹ suggests reviewing your plan’s coverage policy for hyperhidrosis, the medical term for excessive sweating, before treatment.¹ Ask your insurer:

• Is this treatment covered for hyperhidrosis?
• Does it need prior authorization?
• What treatments do I need to have tried first?
• What documentation do you want from my doctor?

Get the answers in writing, or note the date, time and name of the person you spoke with.²

2. Document what you’ve already tried

Insurers often want to see that simpler treatments came first. The Society advises documenting every treatment you’ve tried before you ask for coverage.¹ List each product or prescription, how long you used it, how you used it and why it didn’t work, such as too little effect or skin irritation.

Keep a short sweat diary, too. Note where you sweat, how often you change clothes, and what it gets in the way of: work, social plans, sleep or skin problems.

3. Ask your clinician for the right paperwork

The Society offers templates clinicians can adapt:¹

• A preauthorization request that records the diagnosis, how sweating affects daily life, the treatments tried and the treatment being requested.
• A letter of medical necessity explaining why the treatment is needed.

It also lists the diagnosis codes insurers use, such as L74.510 for primary focal hyperhidrosis of the underarms.¹ Ask your clinician’s office whether they’ve used these forms and who handles prior authorizations.

4. If the answer is no, appeal

For many health plans, HealthCare.gov² lays out a two-step process.²³

Internal appeal. File within 180 days of the denial notice. Include your claim number, insurance ID, the denial letter and any supporting letter from your doctor. Your insurer must decide within 30 days for a service you haven’t had yet, or 60 days for one you’ve already received.²

External review. If the internal appeal is denied, you can ask for an independent external review within 4 months. Standard reviews are decided within 45 days, urgent ones within 72 hours, and the insurer must accept the reviewer’s decision.³

Your state’s Consumer Assistance Program or Department of Insurance can help you file.³ If you have Medicare or another type of plan, ask your plan which appeal process applies to you.

5. Ask about other ways to pay

The Society mentions manufacturer assistance programs and clinical trials as other routes to treatment.¹ If a prescription is involved, ask your pharmacist whether a savings program or a lower-cost alternative exists.

Try: “My insurer denied coverage for my sweating treatment. Can your office help me file a prior authorization with a letter of medical necessity and the list of treatments I’ve already tried?”

Arms Up includes a Fresh Log and four-point sweat scale. Use them to record how much you sweat and what you’ve tried, so you have the documentation insurers ask for. See the book.