Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Varicosities
Treatment: Outpatient procedure 36471 x 3, sclerotherapy
The insurer denied coverage for outpatient procedure 36471 x 3, sclerotherapy
The denial is upheld

This case involves a female who has been recommended to undergo bilateral sclerotherapy due to large varicosities. The submitted documentation indicated that the patient underwent a duplex ultrasound. The results revealed no evidence of venous reflux to the right or left lower extremity. The documentation indicated the patient underwent injection sclerotherapy to the right leg. The documentation indicated another time that she also underwent sclerotherapy to the right leg. The documentation also includes a note indicating the patient underwent an additional session of right lower extremity sclerotherapy. An appeal document indicated the patient has been recommended to undergo bilateral sclerotherapy due to ongoing symptoms. She has had several treatments of sclerotherapy that have improved her symptoms however she continues to have consistent pain, swelling and discomfort. She has tried exercise as well as medications and compression stockings according to the provided appeal document.

Her past medical history of symptomatic varicose veins of the lower extremities and obesity that has been scheduled for sclerotherapy treatments.

Her vascular history is one of chronic lower extremity pain, discomfort and fatigue to the areas of the legs with dilated varices. The patient has been under the care of a Vascular Surgeon for a few years. Conservative management with weight loss, avoiding prolonged standing, and compression stocking therapy has been tried without success.

Workup with lower extremity venous reflux studies revealed no evidence of deep venous reflux or superficial venous reflux. Specifically, there is no evidence of reflux in the bilateral great saphenous vein (GSV), small saphenous vein (SSV) or perforator veins or tributaries. Vein sizes, however, per the duplex scan reveal the GSV at the proximal, mid and distal thigh >3 millimeter (mm) bilaterally. The GSV below the knee is <3 mm in size bilaterally.

She has previously had sclerotherapy with some success but still with residual symptoms. No pictures were given for comparison of pre/post sclerotherapy sessions.  

The claims for repeat sclerotherapy procedures have been denied by her insurance.  

After reviewing all the given documentation, it is determined that future sclerotherapy sessions would add little benefit to her treatment and thus the current application should be denied.

Per the given documentation, the history and physical documents no edema, bronzing or lipodermatosclerosis skin changes, ulcerations, enlarged varicose veins, or itching or cellulitis. Only spider telangiectasias (C1) are noted. Thus, with the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification, this is only C1 disease. 

Ultrasound reveals no evidence of superficial venous reflux at any level. There is no evidence of deep venous reflux or deep vein thrombosis (DVT). The benign nature of the clinical exam, and the absence of any findings on venous reflux studies results in a conclusion of only spider veins or telangiectasias. With such clinical and ultrasound findings, treatment is usually considered cosmetic.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.   
        
The insurer's denial of coverage for the outpatient procedure 36471 x 3, sclerotherapy is upheld. Medical necessity is not substantiated.