Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose veins
Treatment: Stab phlebectomy
The phlebectomy is medically necessary.

The primary basis for denial is that "documentation does not show the treatment to be performed concurrently with or after saphenous vein stripping or ablation per required criteria". The requirement that phlebectomy can only be done concurrently with or after saphenous vein stripping or ablation exists in the health plan policy. However, this requirement is not consistent with published clinical data or consensus guidelines for phlebectomy. When other criteria are met (see discussion below), phlebectomy is widely accepted as medically necessary in the absence of concurrent or prior saphenous ablation.

It should be noted that the denial letter incorrectly describes CPT 37785 as a code for sclerotherapy. The correct definition of this code is "Ligation, division, and/or excision of varicose vein cluster(s), 1 leg".  Additionally, the letter states that CPT 37799 is not the correct code for stab phlebectomy. This statement is incorrect. CPT 37799 (unlisted code) is the code that is supposed to be used for stab phlebectomy when fewer than ten stab incisions are used.  All of the codes requested by the provider are alternative codes for phlebectomy:
37766 is for phlebectomy with 20+ stab incisions
37765 is for phlebectomy with ten to 20 stab incisions
37799, the unlisted code, is used for phlebectomy with under ten stab incisions
37785 is used for phlebectomy of a single varicose vein cluster.

The provider (AP) has proposed left leg phlebectomy for this patient who has minimal axial saphenous reflux. In order to evaluate the medical necessity of the service, widely accepted standards will be applied [1-3]. Under these standards, phlebectomy is appropriate when:

a) There is no axial saphenous reflux, or any associated axial reflux has been treated. If axial reflux has been treated, a sufficient waiting period (usually four to six weeks minimum) should elapse to allow for evaluation of the patient's residual leg symptoms.

b) The patient has symptoms of venous insufficiency severe enough to interfere with normal function.

c) The patient's varicose veins are large enough to account for the symptoms.

d) The patient has failed a trial of medical grade compression stockings.

Requirement (a) has been met. The patient's venous reflux study does not show clinically significant axial reflux. She has only focal reflux in separate segments of the greater saphenous vein.

Requirement (b) has been met. The office notes show that the patient has symptoms of venous insufficiency severe enough to adversely affect normal function. The appeal letter corroborates and elaborates upon the history reported in the office notes.

Requirement (c) has been met. The physician has documented that the veins to be treated are ropey. The venous duplex also confirms the presence of varicosities in both legs.

Requirement (d) has been met. The record shows that the patient has been using prescription-grade compression stockings regularly with only minimal relief of symptoms. She has undergone an unsuccessful, monitored trial of stockings.

Therefore, in summary, the patient meets published, well accepted criteria for performance of phlebotomy.