Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1:  This case involves a 29-year-old woman with a history and venous duplex consistent with venous insufficiency. The patient has requested authorization for endovenous laser therapy. However, the Health Plan denied her request indicating that endovenous ablation, via either a laser or radio-frequency energy source, is investigational and not a covered benefit. At issue is whether endovenous laser therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Endovenous ablation is well studied and there are numerous publications including the recent article by Merchant et al. and a randomized, prospective trial conducted by Hinchliffe et al., which compared stripping to endovenous ablation for recurrent saphenous disease. The two techniques, laser and radiofrequency ablation (RFA), are more or less interchangeable and are primarily a matter of physician preference.  This patient is clearly a candidate for endovenous ablation based on her documented symptoms. Endovenous laser therapy is an accepted alternative to vein ligation and stripping and is widely used by the vascular community.  In fact, most venous surgeons now perform endovenous ablation instead of stripping.  Therefore, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2:  The patient is a 29-year-old female who meets criteria for venous surgery; she has documented symptomatic varicose veins on ultrasound and has failed conservative therapy. Her provider has recommended endovenous laser therapy (EVLT). The Health Plan indicates EVLT is considered experimental and has denied authorization for the therapy.The minimally invasive alternatives to high ligation and stripping for symptomatic varicose veins include VNUS closure and EVLT, which both involve ablating the greater saphenous vein either by radiofrequency or by laser. Since the year 2000, minimally invasive EVLT has been approved by the Food and Drug Administration and has been widely used with well-documented safety and efficacy, and with less morbidity and recovery time. The mid-term data suggest good results after 6 months and the 2-year data is also supportive. EVLT is becoming the new standard for treatment of varices and is an appropriate alternative to high ligation/stripping. Therefore, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3:  The patient is a 29-year-old female with complaints of right leg aching, discomfort, and swelling. She was noted to have Class II CEAP chronic venous insufficiency. Only mild venous reflux was noted at the right greater saphenous vein. She has telangiectasias and accessory varicosities. After discussing the available treatment options with her provider, the patient has decided that she prefers to undergo endovenous laser therapy and has requested authorization and coverage for the treatment. The Health Plan has denied her request.Endovenous laser therapy has been used with success and peer-reviewed journals have reported reasonable results. However, it has not been shown that endovenous laser therapy is more effective than current excisional therapy in terms of recurrence. Thus, there is not sufficient evidence that endovenous laser therapy is likely to be of greater benefit than standard surgical procedures. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.