Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Varicose veins.
Treatment: Medical procedure 37785LT x 4.

The insurer denied coverage for medical procedure 37785LT x 4.  The denial is overturned.

Medical records document prior left great saphenous vein (GSV) ablation previously performed. The patient presented with recurrent large varicose veins left leg. Veins are documented to be "extremely painful with associated swelling." Interference with daily activity is documented: "she is a hairdresser and is on her feet for long periods of time and has significant discomfort that interferes with her job responsibilities." Further, it is documented that "she has been wearing compression stockings for several years without significant relief." Physical exam documents "Large ropey varicose veins" of the "anterior thigh, lateral thigh and lateral calf." (The exam notes seem to erroneously state that the veins are on the right leg). Continued conservative therapy is recommended and plans for phlebectomy of the large symptomatic veins are reported. Ultrasound records report large varicose veins left leg with diameters up to 11 millimeters (mm).

Phlebectomy is and has been a well-established universally recognized part of the standard of care for treatment of varicose veins for centuries and remains so today. 

This procedure does have regulatory approval. It is a straightforward, office-based, very minor surgical procedure performed under local anesthesia in the physician's office. 

The patient is an excellent candidate for the procedure. The procedure requested is the recommended approach in evidence-based, peer-reviewed, expert consensus, multiple society-endorsed guidelines for care of patients with this condition. The recommended procedure is the standard treatment. The risks are not increased over other standard procedures. 

The recommended procedure is the standard treatment/service for patients with this condition. It is likely to be more beneficial than any non-standard approaches and is supported by a large body of evidence-based peer reviewed literature including expert consensus peer reviewed multiple society endorsed specialty guidelines.

"Venous reflux disease or venous reflux, which may also be referred to as chronic venous insufficiency, is a common condition. Venous reflux is usually the underlying cause of varicose veins, reticular veins, and telangiectasias (spider veins). In the lower extremities, venous reflux is categorized as superficial or deep. Superficial venous reflux involves the great and small saphenous veins and their tributaries, which are located between fascia and skin, and is treatable by a number of modalities including endovenous ablation, stripping, or avulsion. Deep venous reflux involves the femoral and other deep veins, which are located below the fascia, and is not readily treated by endovascular methods." (Antani, M. R., & Dattilo, J. B., 2022)

"Ambulatory phlebectomy is a well-known and widely used procedure for residual symptomatic venous disease. Tumescent anesthesia complements the procedure, providing the ability to perform this intervention in a wide range of practice settings. The procedures are well tolerated by most patients, and complications are rare. They include venous thromboembolism, infection, and hematoma and are generally simple to manage. Alternative and emerging techniques of powered phlebectomy and cyanoacrylate glue are providing alternative forms for treatment and will advance the practice further." (Geersen, D. F., & Shortell, C. 2018)

The carrier's denial of medical procedure 37785LT x 4 should be overturned.