Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Varicose veins. 
Treatment: Procedure codes 36471-RT (right) and 36475-RT. 
The insurer denied coverage for procedure codes 36471-RT and 36475-RT. 
The denial is upheld. 
 
This is an adult female patient with varicose veins. The physical exam shows no edema or discoloration and does not describe the presence of varicosities. Medical records report that the patient has a painful right leg. Varices, which have been increasing in size and pain, interfere with daily activity as a teacher who is standing for her workday. Compression stockings have not provided significant relief. An ultrasound demonstrated reflux of 1.7 seconds in the right great saphenous vein, with two local incompetent perforators associated with symptomatic varices. There are images that demonstrate some very small visible varicosities. The treating provider has requested endoluminal radiofrequency ablation of the refluxing great saphenous vein as well as treatment of the perforating veins with sclerotherapy (procedure codes 36471-RT and 36475-RT), which is under review. 

According to evidence-based peer-reviewed expert consensus, multiple society-endorsed nationally accepted published guidelines are cited below. Endovenous ablation of the great saphenous vein as requested in this case is indicated when patients have legitimate symptoms of venous insufficiency and axial reflux in the vein. Axial reflux is clearly defined in these guidelines as a reflux, extending from the groin to the ankle on the course of the great saphenous vein. In this case, there is a minimal segment of the saphenous vein showing reflux. It is outside of the standard of care and is a detriment to the patient (to the loss of the saphenous vein that may later be necessary for coronary bypass or other procedures) to ablated (destroy) the entire length of the saphenous vein based upon reflux in the short segment described of the ultrasound. 

Therefore, the ablation procedure does not qualify as medically necessary. The same nationally accepted guidelines clearly state that treatment of perforator veins is appropriate for patients with ulceration and is rarely necessary in the absence of ulceration. 

Therefore, the request for procedure codes 36471-RT and 36475-RT are not medically necessary and are denied. 

"There are only two current recommendations on venous disease-avoiding ultrasound in patients with asymptomatic spider veins and inferior vena cava filters for prophylaxis.... 

We have all seen these questionable practice patterns in various incarnations for our patients with venous disease: exaggeration of leg complaints in the patient history; documentation of nonoperative measures like compression stockings when none had been worn; misclassification of exam findings to higher severity categories; incomplete, focused, and quick "look" ultrasound exams specifically performed to identify only venous reflux in the superficial system but no evaluation of the deep system; nonaccredited venous ultrasound testing without use of defined venous duplex criteria; falsification of ultrasound results; financial incentives to ultrasound technologists to find reflux; scare tactics pushing operative corrections; and staged multiple endovenous ablations on the same leg." (Passman M. A., et al 2019) 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for procedure codes 36471-RT and 36475-RT is not substantiated.