Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Varicose veins
Treatment: Outpatient procedure 36475 x (times) 1
The insurer denied coverage for outpatient procedure 36475 x 1.
The denial is upheld.
 
This is an adult with a history of varicose veins. The patient presented to the Vascular Surgeon's office for an ultrasound of the right lower extremity due to varicose veins. The physician recommended outpatient procedure 36475 x (times) 1. 

A single medical record is provided for review. This is a report that includes results of a venous ultrasound. The date on which the ultrasound was performed is not present on the document. The ultrasound results state that there is "VVI" (presumed to refer to "Venous valve insufficiency") in the right deep venous system and right GSV (great saphenous vein). However, contrary to accepted standards, the degree of reflux in milliseconds is not reported. 

There are no medical records describing history, physical exam, consultation, follow up, presence or absence of symptoms characteristic of venous insufficiency, no record documenting presence or absence of impact on daily activity of any symptoms that might be present, and no record documenting the benefit (if any) of conservative measures in mitigating or relieving what symptoms might be present.

Performance of invasive procedures such as that requested for this patient is considered medically necessary for persons with legitimate, bonafide, well documented symptoms of venous insufficiency severe enough to result in impact on daily activity or function, and refractory to conservative care, and in the presence of superficial vein reflux exceeding 500 milliseconds (ms) in the veins to be treated. In this case the presence/absence of symptoms, presence/absence of impact on daily activity, presence or absence of benefit from conservative care, and the degree of reflux in the GSV (great saphenous vein) are not documented. This is reflected in the Intersocietal Accreditation Commission (IAC) guidelines cited below. While accreditation by the IAC is not mandatory under the standard of care, the standards promulgated by this amalgamation of seventeen professional societies responsible for care of patients with venous disease legitimately represent standards of care for these patients.

The decision and the choice of treatment for varicose veins are based on the severity of the venous insufficiency, risk of postoperative complications, and patient preferences. Management options for varicose veins include conservative treatment and surgical intervention. Asymptomatic patients with varicose veins are initially managed with conservative treatment options that include medicine, compression therapy, and lifestyle modifications, while symptomatic patients are suggested to consider surgical options[1] that include endovenous laser ablation (EVLA), radiofrequency ablation (RFA), high ligation and stripping (HL/S) of the incompetent great saphenous vein (GSV).
 
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 outpatient procedure 36475 x (times) 1 is not substantiated.