Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Varicose Veins.
Treatment: Vein Treatment (sclerotherapy), Pre-service.
The insurer denied the Vein Treatment (sclerotherapy), Pre-service.
The denial is upheld. 

The patient is a female who is being evaluated for treatment of bilateral lower extremities venous disease. This patient had Left GSV (great saphenous vein) ablation and Right GSV (great saphenous vein) ablation. As per clinic note, this patient complains of bilateral cramping, pain, heaviness, swelling, restlessness, aching, and swelling.

As per Letter, this is a review for bilateral CPT (Current Procedural Terminology) 36465 of the Right and Left accessory/saphenous tributary vein in right and left medial calf.

No, the health plan should not cover the sclerotherapy.
The request is an example of overcoding. Additionally, there is a lack of limiting symptoms.

This provider is requesting 36465 of bilateral calf saphenous tributaries and not a named saphenous truncal vein (See Venous Duplex): 4.4 mm (millimeters) on left and 5.4 on right in the medial calf.

Code-36465 injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great and small saphenous vein and named accessory saphenous veins).

As per the CPT (Current Procedural Terminology) Procedural Manual:

CPT (Current Procedural Terminology) 36465 is the endovenous treatment of saphenous truncal reflux disease [1]. This CPT (Current Procedural Terminology) Code is not used to treat tributaries. It is considered as equivalent to CPT (Current Procedural Terminology) 36478 (Laser Ablation) and CPT (Current Procedural Terminology) 36475 (Radiofrequency ablation). As such, the use to treat a single saphenous tributary is considered as overcoding.

The vein to be treated with the proposed CPT (Current Procedural Terminology) 36465 is described as a right and left calf saphenous tributaries. CPT (Current Procedural Terminology) codes 36465 and 36466 are limited to reporting treatment with non-compounded foam in truncal veins only. The AMA (American Medical Association) has further defined truncal veins as the GSV (great saphenous vein), SSV (short saphenous vein), AASV (anterior accessory saphenous vein), VOG (Giacomini vein), and PAV (Posterior Accessory Saphenous Vein). Tributary and perforator veins are excluded from this description and would be reported with 36470 and 36471 [3].

Therefore, given the above, the Request for CPT (Current Procedural Terminology) 36465 is over coding. The standard of care for patients such as this would include CPT (Current Procedural Terminology) 36470 bilaterally.

No, the requested therapy is not likely to be more beneficial.
As documented above, the Request for CPT (Current Procedural Terminology) 36465 is over coding. The standard of care for patients such as this would include CPT (Current Procedural Terminology) 36470 bilaterally.

However, as per the medical literature and National Guidelines [5, 8, 9, 10, 12, 14, 15, 16, 18], the appropriate and in accordance Generally Accepted Standard of Medical Practice for the treatment of any venous disease including as requested for this patient sclerotherapy of a single saphenous tributary in the right and left calf requires not only significant documented venous reflux disease (See Venous Duplex) but also, significantly related venous symptoms, which is not well-documented in this case.

This patient reportedly complained of many known venous related symptoms, including bilateral pain, cramping, heaviness, swelling, restlessness, aching, and throbbing along with typical generic reference to limitations of daily activities including specifically exercise, activities of daily living, interactions with family, sleeping, and self-esteem.  However, the true actual significance of these symptoms is not at all well-documented; and more importantly, this provider did not document at all well the exact and very specific ways this patient's symptoms of venous disease has caused true limitations of potential daily activities and functions in the submitted medical records.