Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Venous Insufficiency

Treatment code 36478, treatment of varicose veins, great saphenous vein or small saphenous vein ligation/division/stripping, radiofrequency endovenous occlusion (VNUS procedure), and endovenous laser ablation of the saphenous vein (ELAS)

The insurer denied coverage for code 36478, treatment of varicose veins, great saphenous vein or small saphenous vein ligation/division/stripping, radiofrequency endovenous occlusion (VNUS procedure), and endovenous laser ablation of the saphenous vein (ELAS)

The denial is overturned

This case involves female diagnosed with chronic venous insufficiency.  Prior treatment included medications, compression, elevation, and exercises.  According to a bilateral venous reflux evaluation, there was no evidence of deep vein thrombosis (DVT) or superficial thrombophlebitis in the bilateral lower extremities. There was significant bilateral lower extremity venous reflux disease.  According to an evaluation, the patient had leg swelling and heaviness was getting worse. There was increase in veins. Symptoms in the lower extremities were progressively worsening over the prior 6 months. There was increased restless legs, swelling, and pain. On examination, spider veins are present bilaterally. There was tenderness and ankle swelling. The patient was recommended for an ultrasound and continued treatment.  The patient underwent a right endovenous ablation to the small saphenous vein (SSV).  She underwent a left endovenous ablation to the SSV.  On a right venous reflux evaluation, there was significant right lower extremity venous reflux disease.

The patient underwent a right endovenous ablation to the great saphenous vein (GSV). The patient underwent an ablation to the right GSV.

A bilateral venous reflux evaluation revealed no evidence of DVT of the bilateral lower extremities. The patient was status post below-knee Microfoam ablation and left posterior thigh ambulatory phlebectomy. The right GSV remains closed above the knee, status post endovenous ablation.

This is a case of a female with long-standing complaints of bilateral Right and Left leg pain, edema, tightness, and difficulty walking for many years. It had affected her quality of life and was lifestyle limiting.

She was then seen by the provider and worked up for chronic venous insufficiency appropriately with exam and history and venous reflux studies.

The venous reflux studies document bilateral SSV reflux and right GSV reflux. The vein sizes and reflux all fit the criteria as established for treatment by her insurance plan, as do her symptoms, and her failure of conservative management with elevation, compression stockings and avoidance of prolonged standing.

Thus, with documented reflux, associated symptomatic status, and failure of conservative management, this is a case where the denial should be overturned, and the procedures requested should be approved.

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 code 36478, treatment of varicose veins, great saphenous vein or small saphenous vein ligation/division/stripping, radiofrequency endovenous occlusion (VNUS procedure), and endovenous laser ablation of the saphenous vein (ELAS) is overturned. Medical Necessity is substantiated