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

The patient is a 40-year-old man with severe symptomatic varicose veins, which have been refractory to medical therapy. The patients provider has recommended endovenous ablation. The Health Plan has denied authorization for the requested procedure on the basis that endovenous ablation is considered investigational.The submitted information demonstrates that this patient has symptomatic varicose veins, which have not responded to conservative therapy. Review of the current literature demonstrates that endovenous ablation has the same clinical efficacy with shorter recovery time and appears to have greater patient acceptance. Endovenous ablation is a minimally invasive alternative to standard surgery and is appropriate for this patient. Therefore, 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 2The patient is a 40-year-old man who has varices with duplex proven greater saphenous vein and superficial femoral vein insufficiency. The patient had a bout of phlebitis in 2001, which responded well to conservative management. The documentation from the patients provider does not include objective physical findings (e.g., stasis dermatitis, edema, etc.) or symptoms. The patient has requested authorization for endovenous ablation. The Health Plan has denied the request on the basis that the requested procedure is considered experimental.Based upon the submitted documentation, it has not been established that any intervention is medically indicated. The only documented symptomatology is a bout of superficial phlebitis that responded well to conservative management. Thus, given the absence of documented symptoms, it has not been demonstrated that standard treatment modalities are not likely to be effective for treatment of the patients condition. 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 3The patient is a 40-year-old male who had superficial phlebitis of the left leg in 2001. He received conservative care of the upper legs and compression stockings. In December 2003, it was noted the patient presented with recurrent and larger varicose veins of both legs. Non-invasive studies showed left saphenous insufficiency and a large accessory saphenous vein in the right side groin. In addition to ligating the large right tributary, the patients provider has recommended endovenous ablation. The Health Plan has denied authorization for endovenous ablation on the basis that it is considered experimental.Endovenous ablation of varicosities has been used with success and peer-reviewed journals have reported reasonable results. However, it has not been shown that endovenous ablation is more effective than current excisional therapy in terms of recurrence. Thus, there is not sufficient evidence that endovenous ablation is likely to be of greater benefit than standard surgical procedures. 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.