Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose veins

Treatment is outpatient procedure codes 37765 x 1, 37766 x 1, and 37799 x 1, stab phlebectomy

The insurer denied coverage for outpatient procedure codes 37765 x 1, 37766 x 1, and 37799 x 1, stab phlebectomy
 
The denial is overturned

This case involves a patient diagnosed with varicose veins who is being recommended for stab phlebectomy of the right lower extremity. The information provided for the review noted that the patient underwent a duplex ultrasound on noting that there was no evidence of great saphenous venous reflux in the right lower extremity. The proximal calf small saphenous vein had reflux, but there was no deep vein thrombosis and no deep vein reflux. The patient was seen for examination of the right leg symptomatic for varicose veins and endorsed discomfort with throbbing, heaviness, fatigue, and aching in the varicosities. She had worn compression stockings with minimal relief and endorsed that her job required her to remain on her feet for long durations, with symptoms interfering with her daily activities. Physical exam findings noted moderate varicosities of the right posterior calf with no significant edema, lipodystrophy changes, ulcerations, cellulitis, or phlebitis. 

The Milliman Care Guidelines (MCG) state that stab phlebectomy may be indicated when all of the following are present to include that the patient has superficial tributary varicosities that are 3 mm (millimeters) or more in diameter when standing, when the procedure will be performed concurrently with or after saphenous vein stripping or ablation, when saphenous venous insufficiency symptoms cause functional impairment, to include bleeding ruptured superficial varicose veins, leg edema, fatigue, pain, persistent recurrent superficial thrombophlebitis, persistent and recurrent venous stasis ulcers, or skin changes.  The patient should have no clinically significant lower extremity arterial disease, no deep vein thrombosis on duplex ultrasound or other imaging test, have no lymphedema or severe peripheral edema in the region of the procedure, and no overlying infection.  Alternative literature has noted that non-saphenous and smaller veins can be removed via phlebectomy, during which a scalpel or large-gauge needle is used to create punctures every 2 to 3 cm (centimeters) along a varicose vein. Segments of the damaged vein are removed using forceps or small hooks. The decision of the treatment for varicose and reticular veins can be made independent of intention to treat axial reflux (such as via ablation), and in some cases symptoms from varicose veins may exist without the presence of axial reflux in larger veins. In practice, specific treatments are based largely on physician and patient preference in conjunction with symptomatology. Entities that can be treated with ambulatory phlebectomy include asymptomatic varicose and reticular veins, symptomatic reticular and varicose veins, and complications of varicose veins. 

 In the case of this patient, she was noted to have a compressible small saphenous vein with no evidence of intraluminal thrombus and evidence of reflux in the proximal calf. She was being recommended for phlebectomy only given that she did not have any significant reflux affecting the larger veins. While it was noted that the MCG guidelines do not support phlebectomy unless the patient is concurrently undergoing ablation or sclerotherapy, given the findings on duplex ultrasound and examination, the patient did not require ablation or sclerotherapy and could be treated effectively with the stab phlebectomy. The surgical procedure should be left up to the discretion of the physician and in taking the patient's best interest into consideration based upon their individual circumstances. 

The insurer's denial of coverage for outpatient procedure codes 37765 x 1, 37766 x 1, and 37799 x 1, stab phlebectomy is overturned. Medical Necessity is substantiated.