Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Varicose Veins
Treatment: Leg vein procedure CPT (current procedural terminology) 37765 (Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions) x 2 and 37766 (Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions)

The insurer denied coverage for leg vein procedure CPT (current procedural terminology) 37765 (Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions) x 2 and 37766 (Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions)

The denial is upheld 

The patient is seeking coverage for leg vein procedure CPT (current procedural terminology) 37765 (Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions) x 2 and 37766 (Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions).  The patient presented for initial evaluation of the bilateral lower extremities.  The patient had varicose veins of both lower extremities, left worse than right.  The patient reported that the veins popped out during pregnancies.  They were painful.  The patient complained of burning and throbbing. The patient had worn compression stockings but did not find them to significantly impact symptoms. The patient was a former smoker.  The physical exam findings of the patient noted large ropey varicosities in both legs, left worse than right.  Both thighs had varicosities in the medial and anterior aspects. The left medial calf had large varicosities. The patient had worn compression stockings for greater than 12 weeks, regularly exercised, and elevated the legs. The patient felt the symptoms interfered with activities of daily living. There was a plan for reflux study.

The patient presented for lower extremity venous reflux study.  The patient had bilateral lower extremity varicose veins that were worse in the left leg than the right.  The impression reported that there was patent deep venous system with no thrombus. The right accessory saphenous vein had significant insufficiency. The left greater and accessory saphenous vein had significant insufficiency. Varicosities were seen in both calves.

In telephone communication notes, it was stated that the patient could proceed with phlebectomies. The patient did not need ablation.

The request for leg vein procedure CPT 37765 (Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions) x 2 and 37766 (Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions) was denied.  The records did not show that the patient's surface veins were more than 3 millimeters (mm) when standing.  The documentation also did not detail that the patient was having a procedure in conjunction with vein stripping or ablation.

In this case, the patient had symptomatic bilateral lower extremity varicose veins.  The patient reported ongoing pain.  There was a plan for phlebectomy.  However, the documentation did not detail that the varicosities were 3 mm or more in diameter when standing and the documentation did not detail that the treatment would be utilized in conjunction with or after saphenous vein stripping or ablation.  Therefore, proceeding with the request is not recommended.  

The healthcare plan acted reasonably and with sound medical judgment, and in the best interest of the patient.  As such, the denial of coverage for leg vein procedure CPT 37765 (Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions) x 2 and 37766 (Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions) is upheld.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Leg Vein Procedure CPT 37765 x 2, 37766) is not substantiated.