Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins
Treatment: Endovenous Ablation Therapy
The insurer denied the Endovenous Ablation Therapy.
The determination is overturned.

The patient presented with right leg symptomatic varicose veins. Her main symptoms included leg cramping, leg pain, heaviness and swelling. Her symptoms persist despite prior ablation of the main great saphenous vein. Her duplex ultrasound was notable for reflux in her right duplicate great saphenous vein. Her provider recommended endovenous ablation of her right duplicate great saphenous vein (36475 x 1). At issue is the medical necessity of endovenous ablation therapy of incompetent vein.

Endovenous radiofrequency ablation of the right duplicate great saphenous vein is medically necessary for this patient based on the peer reviewed literature.

This patient presented with right lower extremity symptomatic varicose veins which were refractory to conservative therapy, despite ablation of her main right great saphenous vein almost two months prior. The patient attempted conservative therapy with graded compression stockings for several months without symptomatic relief. Her main symptoms included: aching, fatigue and swelling. The patient demonstrated a right duplicate great saphenous vein reflux.

Endovenous ablation of the right duplicate great saphenous vein is the current standard of care treatment for patients with symptomatic varicose veins and saphenous vein reflux. The most recent consensus guidelines for the Society for Vascular Surgery and the American Venous Forum support endovenous thermal ablation for this patient based on her clinical presentation. Endovenous ablation is supported by the peer reviewed literature including level 1 randomized evidence. Several current peer reviewed papers support the use of endovenous thermal ablation for patients with symptomatic varicose veins with excellent results.

Hamann and colleagues demonstrated excellent results with thermal ablation (radiofrequency and laser) in patients with symptomatic varicose veins. They wrote that the current treatment strategy for many patients with varicose veins is endovenous thermal ablation. The most common forms of this are endovenous laser ablation (EVLA) and radiofrequency ablation (RFA). However, at present there is no clear consensus on which of these treatments is superior. The objective of this study was to compare EVLA with two forms of RFA: direct RFA (dRFA; radiofrequency-induced thermotherapy) and indirect RFA (iRFA; VNUS ClosureFast). Patients with symptomatic great saphenous vein (GSV) incompetence were randomized to receive EVLA, dRFA or iRFA. Patients were followed up at 2 weeks, then 6 and 12 months. The primary outcome was GSV occlusion rate. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) score and adverse events. Some 450 patients received the allocated treatment (EVLA, 148; dRFA, 152; iRFA, 150). The intention-to-treat analysis showed occlusion rates of 75.0 (95 percent confidence interval [c.i.] 68.0 to 82.0), 59.9 (52.1 to 67.7) and 81.3 (75.1 to 87.6) percent respectively after 1 year.