Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins
Treatment: Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein modifier RT (36475)
The insurer denied the Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein modifier RT (36475)
The denial is overturned. 

The patient is a female with symptomatic varicose veins. The patient's provider performed ablation of the right greater saphenous vein (GSV). The patient presented with right leg pain and other symptoms and had failed a trial of compression stockings. The procedures were denied by the health plan nf the basis of existing medical policy, which has a size threshold of 5.5 mm (millimeters) for approving GSV (greater saphenous vein) ablation.

Yes, the requested health service is medically necessary.
The patient's provider performed ablation of the right greater saphenous vein (GSV) for this patient with symptomatic varicose veins. The patient presented with right leg pain and other symptoms and had failed a trial of compression stockings. The procedures were denied by the health plan on the basis of existing medical policy, which has a size threshold of 5.5 mm (millimeters) for approving GSV (greater saphenous vein) ablation.

Widely accepted criteria will be applied to assess the medical necessity of the procedures.

Under widely accepted criteria based on randomized trials and cohort studies [1-7], endovenous ablation of the axial saphenous vein and/or perforator veins is medically necessary under the following circumstance:

1.	The patient has venous insufficiency symptoms severe enough to affect normal function
2.	The patient has failed a trial of prescription compression stockings.
3.	The patient has duplex-proven reflux that correlate with the patient's symptoms.

Requirement 1 has been met. The submitted records show that the patient had symptoms of varicose vein disease (burning pain), and that the symptoms were severe enough to adversely affect her normal function. The provider's H&P (history and physical) describes the patient's symptoms in enough detail to show that the symptoms cause substantial adverse impact on the patient's function.

Requirement 2 has been met. The records indicate that the patient failed a trial of compression stockings before undergoing ablation.

Requirement 3 has been met. The reflux study showed severe reflux (>500 msec [milliseconds]) in the right GSV (greater saphenous vein) at multiple levels.

Therefore, the patient meets published, well-accepted criteria for right GSV (greater saphenous vein) ablation.

Note: The previous denial was based on the fact that the policy has a 5.5 mm (millimeters) threshold size for the GSV (greater saphenous vein). In this case, the patient's vein below the saphenofemoral junction measured 4.7 mm (millimeters). The size was 6.5 at the junction itself, but the policy threshold applies to the vein size below the junction.

However, published data demonstrate that vein size does not correlate with patient symptoms [8] and that treatment of small axial veins results in clinical improvement to the same degree observed when treating large axial veins [9]. Thus, there are no data to support having a size threshold for treatment of incompetent axial veins.