Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Venous insufficiency.

Treatment: outpatient service (37765 x 1, 37766 x 1).

The insurer denied coverage for outpatient service (37765 x 1, 37766 x 1).

The denial is upheld.

 
This is an adult female who according to medical records underwent left greater saphenous vein (GSV) ablation. Records document that the patient's pain has been "well controlled" since the procedure. Venous ultrasound documented in the office visit notes reports successful closure of the GSV from the saphenofemoral junction (SFJ) to the knee, with the (normal, expected) patency of the residual GSV below the knee. The note does not describe physical findings or ultrasound findings of varicose veins persisting since the original procedure and reports no symptoms associated with any varicose veins that might be present. The request is for outpatient service (37765 x 1, 37766 x 1), which is under review.

According to evidence-based peer-reviewed expert consensus and nationally accepted guidelines, additional vein treatments are sometimes required for patients who have undergone prior interventions. These treatments are needed when there are legitimate, persistent symptoms (not documented in medical records in this case), physical findings of venous insufficiency such as bulging veins, skin changes, edema (not documented in medical records in this case), and ultrasound findings of pathological reflux in the abnormal veins (also not documented in the medical records of this case). Therefore, the requested procedures do not qualify as medically necessary, and denial of the procedures is in keeping with sound medical judgment and in the best interest of the patient.      

The outpatient service (37765 x 1, 37766 x 1) is not considered medically necessary for this patient.

"Superficial vein reflux can be managed with foam sclerotherapy, endovenous thermal ablation, or stripping. Deep vein reflux may be treated with valve reconstruction or valve transplant. Perforator reflux can either be managed with sclerotherapy, endovenous thermal ablation, or subfascial endoscopic perforator surgery (SEPS). It should be noted, however, that compression therapy regimens that are adhered to are highly effective in treating all forms of venous pathophysiology." (Patel, S.K. & Surowiec, S.M. 2022).

"Venous reflux disease or venous reflux, which may also be referred to as chronic venous insufficiency, is a common condition. Venous reflux is usually the underlying cause of varicose veins, reticular veins, and telangiectasias (spider veins). In the lower extremities, venous reflux is categorized as superficial or deep. Superficial venous reflux involves the great and small saphenous veins and their tributaries, which are located between fascia and skin and are treatable by several modalities including endovenous ablation, stripping, or avulsion. Deep venous reflux involves the femoral and other deep veins, which are located below the fascia and is not readily treated by endovascular methods.
Mild cases of varicose veins just produce leg discomfort, or maybe aesthetically unsightly but severe disease can lead to leg swelling and eventually ulcer formation." (Antani, M. R., & Dattilo, J. B. 2022).

"There are only two current recommendations on venous disease-avoiding ultrasound in patients with asymptomatic spider veins and inferior vena cava filters for prophylaxis...."
(Passman M. A., et al 2019)

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 outpatient service (37765 x 1, 37766 x 1) is not substantiated.