Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Varicose veins of left lower extremity with pain
Treatment: Left sclerotherapy
The insurer denied the left sclerotherapy.
The denial is upheld.

This is a female who has been evaluated and treated for lower extremities venous disease. This patient has bilateral symptoms, left greater than the right. The symptoms have worsened over the last eight months. The patient reports aching, itching, burning and throbbing. Her job requires her to sit for long periods of time. 

Clinic Visit note indicates visit is a follow up to status post left leg phlebectomy for symptomatic left leg varicose veins. The patient is doing well with the exception of some small residual varicosities and large reticular veins that cause her discomfort despite compression. No real limitations of ADLs (Activities of Daily Living) were documented. Plan: discussed with patient the benefit for her with left leg injection sclerotherapy. 

No, the proposed treatment was not medically necessary.

This patient is described as having small varices (type and size not documented) and reticular veins in the left leg.

Sclerotherapy is well supported in the medical literature as a treatment for small varices (usually less than four millimeters) and spider and reticular sized veins. While not considered an indication for treatment, according to the Milliman Care Guidelines, sclerotherapy remains the gold standard treatment for small-caliber venous disease, such as spider and reticular veins. In the medical literature, spider and reticular sized veins are considered one of the indications for sclerotherapy (Schwartz L, et al, Gibson K, et al, Kern P, et al, Myers K, Vitale-Lewis V, Goldman M, Greenberg D, et al); however, the treatment of spider and reticular sized veins is universally considered in the medical literature as a cosmetic procedure.  

Reticular veins are also known as Feeder veins. They are dilated veins that appear bluish or greenish in color and can be dermal and subdermal which may be readily visible to the eye. Some conservative reports suggest that as many as 80% of individuals may have at least a few reticular veins. As such, they are usually considered a cosmetic problem. They do not have any known significant negative impact on health and are not associated with pain, bleeding, ulceration, or other significant medical problems.

Vitale-Lewis V, stated that treatment of venous reflux disease related to  "spider veins" (as she defined to include telangiectasias, venulectasias, and reticular veins) "which is viewed as purely aesthetic".

Goldman M. stated that a majority of patients seek treatment of reticular and spider veins for simply cosmetic indications. 

This is consistent with American Society of Plastic Surgeons: Millions of women are bothered by those small yet unsightly clusters of red, blue or purple veins that most commonly appear on the thighs, calves and ankles. In fact, it's estimated that at least half of the adult female population is plagued with this common cosmetic problem.

Scovell S, et al, Langer L, et al stated that while most telangiectasias (spider veins) and reticular veins are totally asymptomatic, patients often find the cosmetic appearance of their veins "distressing".

Alguire P, et al, American Board of Plastic Surgery stated that while sclerotherapy and surface laser of telangiectasias and subdermal reticular veins often upsetting to patients, they are considered a cosmetic treatment and are not typically covered by insurance, occasionally sclerotherapy will be reimbursed when treating veins that have hemorrhaged. Typically, several treatment sessions are required.

In summary, the veins to be treated with this proposed sclerotherapy are cosmetic in nature. Typical documentation used consider the proposed treatment as cosmetic in nature versus medically necessary include clear, color, up-close, and up-to-date patient photographs with a millimeter ruler marker that clearly documents the veins to be treated with the proposed sclerotherapy. This documentation has not been provided, will not be as they "do not take color photos".

In addition, this patient is repeatedly documented as having bilateral leg symptoms. It is not documented how treating the left leg will cure this patient's claimed bilateral leg symptoms.

The requested sclerotherapy is considered as cosmetic and not medically necessary.