Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose veins. 

Treatment: CPT (current procedure terminology) code 37765 (stab phlebectomy of varicose veins in one extremity with 10-20 stab incisions), CPT code 37766 (stab phlebectomy of varicose veins in one extremity with more than 20 incisions), and CPT code 37799 (unlisted procedure in vascular surgery). 

The insurer denied coverage for CPT (current procedure terminology) code 37765 (stab phlebectomy of varicose veins in one extremity with 10-20 stab incisions), CPT code 37766 (stab phlebectomy of varicose veins in one extremity with more than 20 incisions), and CPT code 37799 (unlisted procedure in vascular surgery). 

The denial is overturned. 

This case involves a female with a history of recurrent varicose veins in the lower extremities, who is being recommended for outpatient procedures consisting of 37765LT (left) X 4, 37766LT X 4, 37799 X 4.  The patient was status post left ablation and sclerotherapy and reported that her left leg remained extremely painful with associated swelling. Her occupation required standing for prolonged periods of time for which she was experiencing significant discomfort, which interfered with her job responsibilities. The patient wore compression stockings without significant relief and was interested in further venous intervention. The lower extremity venous doppler ultrasound report noted that the saphenofemoral junction vein measured 11 mm (millimeters). The greater saphenous vein proximal thigh measures 3 mm, and the greater saphenous vein mid-thigh measures 3 mm. There was evidence of left anterior saphenous vein reflux and deep venous reflux in the common femoral vein.  The patient received a notice of adverse determination stating that while she had problems with certain veins in her legs, in order to approve a stab phlebectomy, the patient would need to have documented evidence of surface veins measuring more than 3 mm when standing. Records reportedly did not confirm this information, and the request was therefore denied.  An appeal indicated that the patient's veins measured 3 mm and it was unclear why the patient's vein measurements would not meet the insurance criteria as the patient's vein measurements were over 3 mm. This review pertains to the outpatient procedure codes 37765LT X 4, 37766LT X 4, and 37799 X 4. 

Literature notes that treatment options for varicose veins include conservative management and interventional therapies such as thermal ablation, endovenous sclerotherapy, and surgery. The decision to proceed with treatment of the choice of treatment are based on symptoms and patient preferences. Records noted that the patient attempted conservative care with compression stockings with no relief. Given her job required standing for prolonged periods of time, this increased the chance of developing the varicose veins. To reduce the symptoms of pain, swelling, and reflux, which continue to contribute to the patient's symptoms, proceeding with surgery would be the next step in the treatment process. Furthermore, given the measurements identified on the doppler ultrasound report, the evidence confirmed that the patient met the criteria for undergoing more invasive treatment of her condition. As such, the request for procedure codes 37765LT X 4, 37766LT X 4, 37799 X 4 are medically necessary.  The prior determination is overturned. 

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

The insurer's denial of coverage for outpatient procedure codes 37765LT X 4, 37766LT X 4, 37799 X 4 is overturned. Medical Necessity is substantiated.