Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins

Treatment: Endovenous Ablation (Treatment for Varicose Veins)

The insurer denied the Endovenous Ablation (Treatment for Varicose Veins).

The denial was overturned.
  
This is a male patient who was evaluated by a radiologist for complaints of left leg pain and swelling.  The patient presented with darkness and swelling of the left ankle that have been present for a few weeks.  The patient had been utilizing a knee sleeve on and off since knee surgery that was performed earlier.  It was reported that the patient had gained 40-pounds since the knee surgery.  The patient's physical examination revealed hyperpigmentation and swelling to the left medial ankle.  The patient underwent a venous duplex that showed a reflux greater than 3 seconds at the greater saphenous vein as well as reflux greater than 1 second at the small saphenous.  The patient's femoral vein also had reflux of greater than 2 seconds.  On the left, the patient's great saphenous vein (GSV) was also enlarged with reflux greater than 3 seconds, anterior accessory saphenous vein (AASV) was enlarged with reflux greater than 2 seconds, small saphenous vein (SSV) enlarged with reflux greater than 2 seconds, and femoral vein had reflux of greater than 1 second. The consulting physician indicated that the patient had been utilizing compression stockings for over six months without significant improvement in pain, swelling or hyperpigmentation. Due to these clinical findings consistent with this patient's symptoms, the recommendation was made for left great saphenous vein radiofrequency ablation.
 
The referenced medical literature indicates the treatment of symptomatic varicose veins should be first managed with conservative treatment including leg elevation, compression therapy, and/or exercise for 3 months treatment. Excision and avulsion of superficial varicosities (i.e., phlebectomy) through multiple tiny incisions is referred to as "micro-stab avulsion phlebectomy" and ambulatory phlebectomy is useful for removing a wide range of non-saphenous and reticular veins. Additionally, the referenced literature notes that correction is indicated for patients with a vein with a documented reflux of greater than 0.5-second duration.

Based on the review of the medical record, the patient has symptomatic left lower leg pain, edema, hyperpigmentation and tightness. The patient's symptoms have not resolved even after 6 months of conservative management, including elevation and compression stockings. The patient's workup with ultrasound reflux studies were appropriate and showed multiple veins being incompetent with reflux times that met the criteria for ablation treatment. The patient's left great saphenous vein (GSV), anterior accessory saphenous vein (AASV), small saphenous vein (SSV) and the vein of Giacomini are all incompetent with reflux times > 2 seconds or 2000 milliseconds and should all have venous ablations performed. Thus, Endovenous Ablation (Treatment for Varicose Veins) is considered medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the requested Endovenous Ablation (Treatment for Varicose Veins) should be overturned.  The medical necessity is substantiated.