Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Varicose veins

Treatment is a vein procedure

The insurer denied coverage for a vein procedure
 
The denial is upheld

According to the medical records, this is a male being evaluated for left leg varicose veins. The patient presented with reports of left leg varicose veins that have become progressively worse. He stands for prolonged periods of time at work and reports he is getting aching, itching, and throbbing that is interfering with his daily activities. He has worn compression with minimal relief. A left leg reflux study demonstrated no evidence of DVT (deep vein thrombosis) or superficial vein truncal reflux. This is an appeal review of the proposed stab phlebectomy.

The health care plan act reasonably and with sound medical judgment and in the best interest of the patient. The proposed treatment at this time would be considered as cosmetic.      

As per the MCG (Milliman Care Guidelines) National Medical Guidelines for Stab Phlebectomies: Stab phlebectomy may be indicated when ALL of the following are present (1)(2)(3)(4): 
-Superficial tributary varicosities that are 3 mm (millimeters) or more in diameter when standing (7)(8) [Not Met]
-Performed concurrently with or after saphenous vein stripping or ablation (11)(12)(13)(14) [Not Met]. No previous saphenous truncal ablations.
-Saphenous venous insufficiency symptoms causing functional impairment, including 1 or more of the following (3)(15)(16)(17): 
Bleeding or ruptured superficial varicose veins
Leg edema
Leg fatigue
Leg pain
Persistent or recurrent superficial thrombophlebitis
Persistent or recurrent venous stasis ulcer
Skin changes (e.g., lipodermatosclerosis, hemosiderosis)
While symptoms are claimed specific limitations of ADLs (activities of daily living) are not at all well documented.

-No clinically significant lower extremity arterial disease (18) [Met]


No deep venous thrombosis on duplex ultrasound or other imaging test (19) [Met]
-No lymphedema or severe peripheral edema in region of procedure (7) [Met: Clinic Notes]

-No overlying infection (e.g., dermatitis, cellulitis) (7) [Met: Clinic Notes]

From the size of veins documented as being less than 3 mm: The proposed veins to be treated are consistent with spider and reticular sized veins. While well treated with stab phlebectomy: Such treatment would be considered as cosmetic.

"Phlebectomy is an historic yet well-validated treatment of superficial venous disease in the form of varicose veins that has been described in the medical literature since the time of Hippocrates (460377 BC (before Christ). 1 Techniques have evolved since that time, notably in the mid-20th century with the work of Swiss phlebologist Dr. Robert Muller and his technique utilizing hook dissectors and multiple small (stab) skin incisions. He is credited with bringing ambulatory phlebectomy into the modern form we know today. 2. In the more recent past, modifications have been made to improve efficacy, outcomes, and patient experience. Today, ambulatory phlebectomy is a method whereby enlarged superficial varicose veins are removed with specialized hooks and clamps via multiple small "stab" incisions. The procedure is typically performed on an outpatient basis with local anesthetic and minimal sedation, frequently in conjunction with axial vein ablation, and is also known as stab phlebectomy, microphlebectomy, and microextraction." (Andrews, R. H. et al. 2021).

"Conclusions: Combined endovenous ablation and phlebectomy delivers improved clinical outcomes and a reduced need for further procedures, as well as early quality of life improvements." (Lane, T. R. et al. 2015).                                                         

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 a vein procedure service is not substantiated.