Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cardiac/Circulatory Problems
Treatment:  Inpatient Hospital

This is a patient who presented with left leg symptomatic varicose veins. Per the documentation provided, his main symptoms include edema, fatigue, discomfort and lipodermatosclerosis.  He has worn graded compression stockings, elevated his legs and taken nonsteroidal anti-inflammatory drugs (NSAIDs) without symptomatic relief.  He has a history of prior great saphenous vein stripping.  His duplex scan demonstrates reflux in his left small saphenous vein. His provider is recommending endovenous radiofrequency ablation of his left small saphenous vein for treatment of his condition.  At issue is the medical necessity of the requested procedure.

The health plan's determination is overturned. 

Left small saphenous vein radiofrequency ablation is medically necessary for this patient based on the peer reviewed literature.  The patient presented with left lower extremity symptomatic varicose veins which are refractory to conservative therapy.  The patient has attempted conservative therapy with graded compression stockings for several months without symptomatic relief.  His main symptoms include: pain, swelling and lipodermatosclerosis.  The patient demonstrates left small saphenous vein reflux.
Endovenous ablation of the great and small saphenous veins is the current standard of care treatment for patients with symptomatic varicose veins and saphenous vein reflux. The most recent consensus guidelines for the Society for Vascular Surgery and the American Venous Forum support endovenous thermal ablation for this patient based on his clinical presentation.  Endovenous ablation is supported by the peer reviewed literature including level 1 randomized evidence.  Several current peer reviewed papers support the use of endovenous thermal ablation for patients with symptomatic varicose veins with excellent results.

Hamann and colleagues demonstrated excellent results with thermal ablation (radiofrequency and laser) in patients with symptomatic varicose veins.  They wrote that the current treatment strategy for many patients with varicose veins is endovenous thermal ablation.  The most common forms of this are endovenous laser ablation (EVLA) and radiofrequency ablation (RFA).  However, at present there is no clear consensus on which of these treatments is superior.  The objective of this study was to compare EVLA with two forms of RFA: direct RFA (dRFA; radiofrequency-induced thermotherapy) and indirect RFA (iRFA; VNUS ClosureFast [tm]).  Patients with symptomatic great saphenous vein (GSV) incompetence were randomized to receive EVLA, dRFA or iRFA. Patients were followed up at 2 weeks, 6 and 12 months.  The primary outcome was GSV occlusion rate. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) score and adverse events.  Some 450 patients received the allocated treatment (EVLA, 148; dRFA, 152; iRFA, 150).  The intention-to-treat analysis showed occlusion rates of 75.0 (95 per cent c.i. 68.0 to 82.0), 59.9 (52.1 to 67.7) and 81.3 (75.1 to 87.6) per cent respectively after 1 year.