Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1: The patient is a 35-year-old female with bilateral symptomatic varicose veins, worse on the right, with lipodermatosclerosis on her left calf. She has undergone phlebectomy and VNUS closure on the right leg in the past. The patient now has reflux on both legs, with 15 mm varices on the right from the mid-thigh down, and 6 mm varices on the left with reflux. The patient is very symptomatic with skin changes on the right leg, and has used compression stockings for years. The patients provider proposed endovenous laser therapy (EVLT) for treatment of the patients left leg and possible sclerotherapy on the right leg. The Health Plan has denied authorization and coverage for EVLT on the basis the requested procedure is considered investigational.Review of the relevant data demonstrates EVLT is not an investigational device. Both VNUS closure and EVLT use the same procedure, i.e., burning the endothelium shaft.  EVLT has a similar safety profile to VNUS closure. The general opinion in the vascular surgery community is that EVLT is not considered investigational. Based upon the findings of the patients vascular surgeon EVLT is a medically reasonable and appropriate option for the treatment of this patients varices. Furthermore, if sclerotherapy is pursued for treatment of the patients right leg varices, it is medically appropriate in this case and should be authorized. Based upon the information set forth above, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a 35-year-old female with symptomatic varicose veins. Reflux of the greater saphenous vein was previously treated in 2003 with VNUS closure. The patient has now experienced a recurrence of varicose veins and saphenous vein reflux below the knee. There is no documentation in the submitted records of deep vein function.  The patients provider has recommended endovenous laser therapy (EVLT) and possible sclerotherapy. The Health Plan has denied authorization and coverage for EVLT citing a lack of peer-reviewed evidence demonstrating the benefits of EVLT.At this time there is insufficient evidence EVLT is likely to result in a better clinical outcome than other available treatment. Review of the scientific evidence does not demonstrate EVLT has been documented to be superior to surgical stripping or radiofrequency ablation. EVLT remains investigational at this time. There are other treatment options available to this patient that demonstrate better efficacy than EVLT such as sclerotherapy, ligation and stripping, stab phlebectomies, and repeat VNUS closure.  Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 35-year-old female who presents with a family history of varicose veins and a history that she developed painful varicose veins at the age of 14. She attempted several conservative measures without success. Her veins worsened. She underwent a phlebectomy in 1990 and radiofrequency ablation of her greater saphenous vein in 2003. Both interventions failed to improve her symptoms. She now complains of an exacerbation of these symptoms with aching, itching, burning, numbness and swelling in both legs. In an attempt to relieve her symptoms, the patient has tried compression stockings, regular exercise and ibuprofen. The patients provider suggests that the patient has numerous telagiectatic veins and large varicose veins bilaterally with areas of lipodermatosclerosis on her right medial calf. The greater saphenous vein on the right measures about 15 mm and the small saphenous vein was enlarged to 3 to 4 mm with reflux from the sapheno-popliteal junction. Radiofrequency ablation appears to have removed the greater saphenous vein at the sapheno-femoral junction, but it appears there is a perforator midway in the thigh that is now feeding the remainder of the saphenous vein on the right side. On the left side she has greater saphenous reflux to the ankle. The patients provider has recommended endovenous laser therapy and possible sclerotherapy. The Health Plan has denied coverage for endovenous laser therapy on the basis it is considered investigational.The paradigm and standard of care has changed for the treatment of greater saphenous vein reflux that is refractory to conservative therapy. Catheter based therapy with either radiofrequency ablation or endovenous laser therapy is now considered standard of care. Endovenous laser therapy is generally accepted and is consistent with current community standards. The submitted clinical evidence suggests the patient is likely to benefit from endovenous laser therapy. In addition, sclerotherapy for treatment of the patients right side varicosities would be medically appropriate. Based upon the information set forth above, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.