Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose veins.
Treatment: Procedure code 36475, endoluminal ablation of varicose veins.
The insurer denied coverage for procedure code 36475, endoluminal ablation of varicose veins.
The denial is overturned.

This is the case of a female with history of varicose veins who was recommended endoluminal ablation of varicose veins. The patient was seen by the provider, she reported pain, achiness, and heaviness of the right lower extremity (RLE) and claimed she never wore compression stockings. A prior duplex venous scan to rule out deep vein thrombosis was negative. She had 1+ edema on the right side and no edema on the left. Varicosities measured 4 millimeters (mm) in diameter on examination of both lower extremities. The symptomatic veins were on the medial aspect of the right leg. When she was seen on follow up, she claimed to have had a hard time tolerating compression stockings and stated they made her condition worse. She was seen on a later visit claiming to have used compression stockings more, doing conservative therapy, and plan to proceed with a definitive surgery for reflux of her greater saphenous vein (GSV) in the RLE given her pain, achiness, heaviness, and edema. The venous duplex scan noted incompetent veins in the right leg with reflux at the saphenofemoral junction measuring 8.8 mm and 976 millisecond (ms) reflux, the GSV measuring 5.8 mm proximal with 1128 ms of reflux, 4.5 mm above the knee with 636 ms of reflux and measuring 3.7 mm below the knee. At the short saphenous vein, the proximal measurement was 4.4 mm with 1326 ms of reflux. On another visit, she presented with RLE edema graded 3+ and complaints of pain. She continued to have heaviness, achiness, and pain despite wearing compression stockings. Her calf circumference on the right side measured 43.5 centimeters (cm) compared to the left at 40 cm. She reported that her pain was sharp at night and affected her sleep and she was occasionally having deep pain while working, which affected her concentration. Records indicated the patient received a notice of adverse determination indicating that she did not have severe problems in her daily life or work caused by the varicose veins, which had not improved with simple treatments. 

The records confirmed that she attempted conservative treatment with compression stockings, conservative therapy, and continued to have pain, achiness, heaviness, and edema affecting her right greater than left lower extremities. Literature notes that varicose veins of the lower extremities manifested by symptoms spanning the clinical spectrum from asymptomatic prominent veins to limb swelling, tissue hyperpigmentation, induration, and ulceration are quite common. Symptoms of varicose veins include a heavy, achy feeling and itching or burning sensation, which can worsen with prolonged standing. Potential complications include infection, leg ulcers, stasis changes, and thrombosis. Conservative treatment options include external compression, lifestyle modifications, such as avoidance of prolonged standing and straining, exercise, wearing nonrestrictive clothing, modification of cardiovascular risk factors, and interventions to reduce peripheral edema to include elevation of the affected leg, weight loss, and medical therapy. Interventional treatments include external thermal ablation, endovenous thermal ablation, endovenous sclerotherapy, and surgery. Given that the patient failed to respond effectively to several months of conservative care directly focusing on addressing the lower extremity issues, proceeding with the ablation procedure would be the next step in the treatment process. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for procedure code 36475, endoluminal ablation of varicose veins is overturned. Medical Necessity is substantiated.