Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cardiac/Circulatory Problems-Varicose Veins. Treatment: Surgical Services-Endovenous ablation and sclerotherapy. 
The insurer denied endovenous ablation and sclerotherapy. 
The denial was overturned in part. 

The patient is a female with bilateral lower extremity symptomatic varicose veins. Her main symptoms include pain, fatigue, heaviness, itching and tingling. Her symptoms interfere with her activities of daily living and are lifestyle limiting. She has attempted and failed conservative therapy with graded compression stockings without symptomatic relief. Her duplex scan demonstrates reflux in her bilateral great and small saphenous veins. 
At issue is whether the service of endovenous ablation and sclerotherapy are medically necessary.
The health plan's determination of medical necessity is overturned in part. Left great saphenous vein ablation and right great saphenous vein ablation are medically necessary and denial is overturned.
The right small saphenous vein ablation, left duplicate great saphenous vein ablation, left below knee great saphenous vein chemical ablation, and right below knee great saphenous vein chemical ablation are not medically necessary and denial is upheld.
The service of Endovenous ablation and sclerotherapy is medically necessary for this patient, in part. According to the documentation provided, her provider is recommending the following treatment plan:
1) Left great saphenous vein ablation - This is medically necessary 
2) Right great saphenous vein ablation - This is medically necessary 
3) Right small saphenous vein ablation -This is not medically necessary 
4) Left duplicate great saphenous vein ablation -This is not medically necessary 
5) Left below knee great saphenous vein chemical ablation - This is not medically necessary 
6) Right below knee great saphenous vein chemical ablation - This is not medically necessary.
The patient has attempted conservative therapy with graded compression stockings for several months without symptomatic relief. 
Endovenous ablation of the proximal bilateral great 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 her clinical presentation. 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.
Additional varicose vein ablations and chemical ablations of the bilateral lower extremities are not medically necessary at this time based on the peer reviewed literature. The patient should be evaluated 3-6 weeks following endovenous ablation of her proximal bilateral great saphenous veins to determine further treatment plan. Additional varicose vein procedures cannot be supported as medically necessary in advance. This is consistent with the current standard of care in the Vascular Surgery community.