Appeal type: Medical necessity
Decision: Upheld

Diagnosis: lower extremity venous disease
Treatment: outpatient surgery (37766LT, 37765LT, 37799LT, 37785LT) x (times) 1
The insurer denied coverage for outpatient surgery (37766LT, 37765LT, 37799LT, 37785LT) x (times) 1.
The denial is upheld.

This is an adult female patient who has been evaluated for the treatment of lower extremities venous disease. She has a history of hearing loss and varicose veins in the left lower extremity. The patient presented to the Vascular Surgeon's office for a left leg reflux study. There was venous reflux in the anterior accessory saphenous vein. The physician recommended a phlebectomy to treat varicose veins. 

Stab Phlebectomy is to be used to treat at least 3 millimeters (mm) varicose veins associated either concomitantly with or after saphenous truncal ablation. This criteria is not met for the requested left leg treatment, outpatient surgery (37766LT, 37765LT, 37799LT, 37785LT) x 1), as this provider has proposed isolated stab phlebectomy. 

As per Scovell. S., "...the treatment of telangiectasias, reticular veins, and small nonaxial varicose veins (< [less than] 6 mm), which may or may not be symptomatic, and even in the absence of symptoms can be a source of significant distress to some patients." Alternative approaches to treatment of telangiectasia, reticular veins, and small, nonaxial varicose veins (less than (<) 6 mm) can include sclerotherapy and stab phlebectomy (as is being proposed for this patient).

As such, the Isolated stab phlebectomy can be considered as mainly cosmetic and therefore is not considered medically necessary for this patient.

"Superficial vein reflux can be managed with foam sclerotherapy, endovenous thermal ablation, or stripping. Deep vein reflux may be treated with valve reconstruction or valve transplant. Perforator reflux can either be managed with sclerotherapy, endovenous thermal ablation, or with subfascial endoscopic perforator surgery (SEPS). It should be noted, however, that compression therapy regimens that are adhered to are highly effective in treating all forms of venous pathophysiology." (Patel, S.K. & Surowiec, S.M.).

"Venous reflux disease or venous reflux, which may also be referred to as chronic venous insufficiency, is a common condition. Venous reflux is usually the underlying cause of varicose veins, reticular veins, and telangiectasias (spider veins). In the lower extremities, venous reflux is categorized as superficial or deep. Superficial venous reflux involves the great and small saphenous veins and their tributaries, which are located between fascia and skin, and is treatable by a number of modalities including endovenous ablation, stripping, or avulsion. Deep venous reflux involves the femoral and other deep veins, which are located below the fascia, and is not readily treated by endovascular methods.

Mild cases of varicose veins just produce leg discomfort, or maybe aesthetically unsightly but severe disease can lead to leg swelling and eventually ulcer formation." (Antani, M. R., & Dattilo, J. B.).                                                         

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 surgery (37766LT, 37765LT, 37799LT, 37785LT) x (times) 1 is not substantiated.