Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 49-year-old woman with symptomatic varicose veins in both legs, which have worsened substantially in the last year. Physical exam reveals bilateral calf varicosities have failed to respond to compression stockings. Duplex scan revealed reflux only in the right greater saphenous vein. The patient wishes to undergo endovenous laser therapy for treatment of her varicose veins. The Health Plan has denied the request indicating the requested procedure is considered investigational for treatment of the patients medical condition. Review of the medical literature reveals endovenous laser ablation for varicose veins has not been scientifically established as an effective treatment modality. Other therapeutic options have extensive supporting literature demonstrating benefit and safety. Radiofrequency ablation or saphenous vein stripping combined with phlebotomies of the calf varicosities are more likely to be beneficial for this patient. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 2: The patient is a 49-year-old woman with symptomatic right leg varicosities and greater saphenous vein (GSV) reflux. The patient indicates she has tried support stockings and NSAIDs without benefit. She requires elimination of GSV to treat her symptoms. The patient wishes to undergo endovenous laser therapy for treatment of varicose veins. The Health Plan had denied authorization for the requested procedure on the basis it is considered experimental. Standard treatment for GSV reflux includes surgical stripping and radiofrequency ablation (RFA), both of which have been documented in the literature as equally safe and effective in short and long-term studies. Endovenous laser therapy is not the standard of care and has not been proven to be as safe and effective as stripping or RFA. The patient can be safely and effectively treated with standard therapies. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 3: The patient is a 49-year-old woman with symptomatic bilateral calf varices with associated reflux on the right leg. Her condition has not responded to medical management. The patient consulted a vascular surgeon who recommended endovenous laser therapy and stab phlebectomy on the right leg. The Health Plan denied authorization for endovenous laser therapy indicating it is considered investigational. The minimally invasive alternatives to high ligation and stripping for symptomatic varicose veins include VNUS closure and endovenous laser therapy, which both involve ablating the GSV either by radiofrequency or by laser. Since the year 2000, minimally invasive endovenous laser therapy has been approved by the Food and Drug Administration and has been widely used with well-documented safety and efficacy, and with less morbidity and recovery time. The mid-term data suggest good results after six months and the 2-year data is also supportive. Endovenous laser therapy is becoming the new standard for treatment of varices and is an appropriate alternative to high ligation/stripping. Based upon the information set forth above, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.