Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral Varicose Veins. 
Treatment: Procedure Code 36475, endoluminal radiofrequency ablation or endoluminal laser ablation. 
The insurer denied coverage for Procedure Code 36475, endoluminal radiofrequency ablation or endoluminal laser ablation. 
The denial is upheld. 

This is adult patient had an ultrasound (US), indicating bulging left leg tributaries of the vein of Giocomeni. No reflux is documented on the ultrasound report in the left great saphenous vein (GSV), small saphenous vein (SSV), or craniocaudal extension of the SSV (also known as the "vein of Giocomeni"). The US shows bulging of the varicose tributary veins of the left leg, and considerably less varicose vein disease in the tributaries right leg. The patient's symptoms are reportedly present in the left leg and include discomfort, edema, and the characteristic of venous dermatitis ("scaling" of the skin about the ankle). Symptoms are unresolved with compression garments. The treating provider has requested endoluminal radiofrequency ablation or endoluminal laser ablation, which is under review. 

There was no reflux documented on the ultrasound report in the left great saphenous vein (GSV), small saphenous vein (SSV), or craniocaudal extension of the SSV (also known as the "vein of Giocomeni"). Destruction (ablation) of a vein without reflux, as in this request for treatment of the left craniocaudal extension of the SSV (also known as the "vein of Giocomeni") is not appropriate and is a deviation from standard of care. 

Therefore, the request for endoluminal radiofrequency ablation or endoluminal laser ablation is not medically substantiated and is 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). 

"Any physician who routinely does more than two ablations in a single setting should examine their indications and vascular laboratory. The data from this study should also be used by Medicare and other insurers to investigate fraudulent venous care. Anyone who routinely performs six to eight ablation procedures in a single setting is either fraudulently billing or doing inappropriate procedures" (Lawrence, P. F., et al 2019).

"The common complications after endovascular laser ablation (EVLA) are bruising (24%-75%), thrombophlebitis (5%), superficial vein thrombosis, deep venous thrombosis (DVT), hematomas and ecchymoses, skin burn, pigmentation, nerve injury, recurrence, and retained fragment of catheter" (Gao, R. D., et al 2022). 

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 endoluminal radiofrequency ablation or endoluminal laser ablation is not substantiated.