Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Varicose Veins. 
Treatment: 36471 - Sclerotherapy. 

The insurer denied the 36471 - Sclerotherapy. 

The denial is upheld. 

The member is a man with greater saphenous vein insufficiency in the region of the right calf which is causing severe pain and interfering with activities of daily living including standing during work. His provider is requesting approval of sclerotherapy. A Doppler test revealed insufficiency of the right greater saphenous vein in the calf with a reflex of 1.5 seconds. The diameter of the vein is 0.37 cm. He has attempted conservative treatment with leg elevation, NSAIDs (non-steroidal anti-inflammatory drugs) and compression stockings for three months, without improvement. 

No, the current standard of care for GSV (greater saphenous vein) insufficiency is endovenous radiofrequency or laser ablation. 

All techniques can be used to adequately treat the great saphenous vein (GSV). Radiofrequency or laser ablation have the most established supporting evidence and are considered the standard to which other endovenous techniques are compared. Mechanochemical ablation (MOCA) and cyanoacrylate glue have excellent closure rates and a low incidence of complications but are newer with less established supporting evidence and are more expensive to perform. 

Polidocanol endovenous microfoam (PEM) may be the best choice for a very tortuous GSV (greater saphenous vein) but must be used carefully to avoid inadvertent extravasation into the deep vein system, which can lead to complications. In addition, several treatment sessions may be needed to effect complete closure of the target vein(s). 

The member has not had surgical treatment of the greater saphenous vein and, therefore, sclerotherapy is not considered medically necessary. 

The Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) have developed clinical practice guidelines for the care of patients with varicose veins of the lower limbs and pelvis. The document also includes recommendations on the management of superficial and perforating vein incompetence in patients with associated, more advanced chronic venous diseases (CVDs), including edema, skin changes, or venous ulcers. Recommendations of the Venous Guideline Committee are based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system as strong (GRADE 1) if the benefits clearly outweigh the risks and burden. The suggestions are weak (GRADE 2) if the benefits are closely balanced with risks and burden. The level of available evidence to support the evaluation or treatment can be of high (A), medium (B), or low or very low (C) quality. The key recommendations of these guidelines are: We recommend that in patients with varicose veins or more severe CVD (chronic venous diseases), a complete history and detailed physical examination are complemented by duplex ultrasound scanning of the deep and superficial veins (GRADE 1A). We recommend that the CEAP (Clinical, Etiologic, Anatomic and Pathophysiologic) classification is used for patients with CVD (chronic venous diseases) (GRADE 1A) and that the revised Venous Clinical Severity Score is used to assess treatment outcome (GRADE 1B). We suggest compression therapy for patients with symptomatic varicose veins (GRADE 2C) but recommend against compression therapy as the primary treatment if the patient is a candidate for saphenous vein ablation (GRADE 1B). We recommend compression therapy as the primary treatment to aid healing of venous ulceration (GRADE 1B). To decrease the recurrence of venous ulcers, we recommend ablation of the incompetent superficial veins in addition to compression therapy (GRADE 1A). For treatment of the incompetent great saphenous vein (GSV), we recommend endovenous thermal ablation (radiofrequency or laser) rather than high ligation and inversion stripping of the saphenous vein to the level of the knee (GRADE 1B). We recommend phlebectomy or sclerotherapy to treat varicose tributaries (GRADE 1B) and suggest foam sclerotherapy as an option for the treatment of the incompetent saphenous vein (GRADE 2C). We recommend against selective treatment of perforating vein incompetence in patients with simple varicose veins (CEAP [Clinical, Etiologic, Anatomic and Pathophysiologic]  class C(2); GRADE 1B), but we suggest treatment of pathologic perforating veins (outward flow duration 500 ms (milliseconds), vein diameter 3.5 mm) located underneath healed or active ulcers (CEAP [Clinical, Etiologic, Anatomic and Pathophysiologic] class C(5)-C(6); GRADE 2B). We suggest treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs, or transcatheter sclerotherapy, used alone or together (GRADE 2B).