Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe venous insufficiency with bilateral leg swelling. 
Treatment: Vascular Surgery/ Open ReVascular, 02 units. 

The insurer denied coverage for Vascular Surgery/ Open ReVascular, 02 units. 

The denial is upheld. 

This is a male patient with a history of severe venous insufficiency with bilateral leg swelling, hypertension, and hyperlipidemia who presented to his Vascular Surgeon for a follow-up.  The patient stated his swelling was unchanged from before.  Pain over thrombosed veins was present to the left thigh.  He did indicate his leg tiredness was much better.  The itchiness had improved as well as knee pain.  He underwent endovenous laser ablation to the bilateral greater saphenous veins.  He has previously utilized compression stockings as well as elevation.  He has been recommended to undergo a bilateral venogram with possible balloon and possible stent placement.  Additionally, the patient was recommended to undergo endovenous laser treatment (EVLT) with sclerotherapy bilaterally as well as a venous duplex, magnetic resonance venography (MRV) and ankle brachial index (ABI) / pulse volume recordings (PVR).  

The procedure of bilateral lower extremity venograms, intravascular ultrasound of the deep venous system, and possible venous stenting of the iliac veins is not indicated at this time.  Based on the most recent venous ultrasound reflux study, there is residual severe superficial reflux in the bilateral lower extremities that must be addressed and treated first, specifically, the right greater saphenous vein (GSV) from the sapheno-femoral junction  (SFJ) to the knee and the bilateral small saphenous vein (SSV).  There is no evidence in this most recent study that there is deep venous reflux.  

After these superficial veins x 3 are treated by either thermal based venous ablation or non-thermal methods, the patient should be followed closely and conservative measures should be continued.  Once that is done, and the patient still has edema, pain, swelling and limitation of daily activities should a search for deep venous pathology be performed.  

This is a patient has a history of hypertension and hyperlipidemia and has had chronic bilateral Left > Right lower extremity edema, pain, and itching and fullness.  He had tried conservative management with elevation and wearing compression stockings for several months, all without significant success.  Venous reflux studies indicated bilateral GSV reflux and thus he underwent bilateral GSV ablations with EVLT.  He continued to have symptoms, and a MRV was performed to rule out deep venous pathology.  By report, it was negative for extrinsic compression of the bilateral external and common iliac veins.  Thus, no May-Thurner disease found bilaterally.  

The patient had another venous reflux study which revealed closure of the right GSV from the knee to the distal calf, consistent with the EVLT and closure of the left GSV from the SFJ to the knee, consistent with EVLT closure.  There was no evidence of deep venous reflux but reflux was found in the superficial system, consisting of the right GSV from the SFJ to the knee and bilateral SSV's.  Of note, the patient reported some improvement of the legs with less itching and swelling.  Thus, the standard future therapy would be continuing with the conservative management, performing the right GSV and bilateral SSV ablations, and then continuing follow-up.  If these maneuvers fail, and patient still has symptoms despite completion of all superficial reflux, then one can contemplate a search of the deep system with venography, intravascular ultrasound (IVUS) and possible intervention. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for Vascular Surgery/ Open ReVascular, 02 units is upheld. Medical Necessity is not substantiated.