Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose veins

Treatment: heat treatment of main leg vein (endoluminal ablation of varicose veins)

The insurer denied coverage for heat treatment of main leg vein (endoluminal ablation of varicose veins)

The denial is overturned

 
The patient is an adult seeking authorization for heat treatment of main leg vein (endoluminal ablation of varicose veins).  The patient had a history of asthma and venous insufficiency.  The patient presented for an evaluation.  The patient had right leg edema and pain during a pregnancy which had now been cyclic in nature in the last few years.  The right leg was chronically larger than the left.  The patient had large varices over the foot and ankle.  Every day, there was increased pressure and heaviness in the leg.  The patient experienced pain with periods and ovulation.  The patient had been told that they had a faulty valve in the leg, but no further intervention has been completed as the patient was pregnant or breast-feeding.  The patient utilized compression stockings as much as they could tolerate with little improvement.  Right leg ultrasound revealed reflux in the distal great saphenous vein proximal calf and mid-calf of 3.7 and 3.9 seconds which gave rise to symptomatic varices.  There was no deep reflux or deep venous thrombosis.  The exam findings of the right lower extremity noted larger circumference than the left.  There is trace edema to the knee.  There were moderate size varices of the calf, foot, and ankle.  The assessment was venous insufficiency.  The patient had residual varices in the right lower extremity.  The leg was painful at times and always felt heavy and uncomfortable with reflux.  The patient was unable to elevate during the day due to obligations to children and work.  The provider stated that the patient would benefit from great saphenous vein closure with assessment for phlebectomy.

Per the referenced sources, proceeding with saphenous vein radiofrequency ablation is recommended in patients with incompetence of saphenous vein documented by duplex ultrasound or other imaging with valve closure time of greater than 500 milliseconds and with saphenous venous insufficiency symptoms causing functional impairment including leg edema, leg fatigue, leg pain, and/or persistent or recurrent venous stasis ulcers.  In this case, the patient had reflux in the distal great saphenous vein proximal calf and mid-calf of 3.7 and 3.9 seconds which gave rise to symptomatic varices.  There was noted leg edema.  The patient described functional impairment which affected her ability to participate in work and take care of children.  There was no deep venous thrombosis on duplex ultrasound.  There was no clinically significant lower extremity arterial disease.  Given the patient's symptoms that were causing functional impairment, proceeding with the request is recommended as medically necessary per standards of care.  The patient is unlikely to have significant symptom improvement with ongoing noninvasive treatment.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for heat treatment of main leg vein (endoluminal ablation of varicose veins) is substantiated.