Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Varicose veins.
Treatment: Medical procedure 37785LT x 4.

The insurer denied coverage for medical procedure 37785LT x 4.  The denial is upheld.

This patient is being evaluated for treatment of left leg venous disease. As per the office visit notes, the patient previously had a left ablation and sclerotherapy injections. The patient has reoccurring large varicose veins in the left leg that are extremely painful and have associated swelling. The patient's occupation also involves standing on her feet for long periods of time, and she has significant discomfort that interferes with her job responsibilities. The patient wears compression stockings but without significant relief. The patient was interested in pursuing further venous intervention, and she had a left leg reflux study at this visit. The lower extremity venous reflux duplex ultrasound report noted the patient's vein diameters were 11 millimeters (mm), 3 mm and 3 mm. The provider documented the study did not show any treatable reflux, and she had positive deep venous reflux. The recommended treatment plan was a left leg phlebectomy for her large palpable ropey varicosities in her left lower extremity using code 37785 LT X 4.

Per the Venous Duplex, there are no documented at least 3 mm in size venous tributaries that have documented reflux. The letter of appeal is incorrect claiming veins of 3mm and 11mm for that is size of the left greater saphenous vein (GSV) remnant that has no documented reflux and likely not being treated. Patient photographs of veins to be treated are needed.      

There are no documented at least 3mm tributaries with documented significant reflux disease. As proposed this treatment would be considered cosmetic.

Unnecessary stab phlebectomy can be associated with wound problems and excessive wound scarring.     

According to Armstrong, D., & Meyr, A. J. (2019), "Compression therapy remains the cornerstone of management for patients with chronic venous disease. For patients with venous ulceration, the benefits of long-term compression therapy (stockings or bandages) have repeatedly been demonstrated in randomized trials. Healing rates as high as 97 percent can be achieved in those who are compliant with therapy. Patients with edema, weeping, or skin changes in the absence of ulceration also benefit. The goals of treatment are ulcer healing and reduction of extent of edema, lipodermatosclerosis, and pain."

Alguire, P. (2018) states, "Epidemiologic studies typically focus on defined subsets based upon the visible manifestations of venous disease. Study populations are generally limited to either those with mild abnormalities (telangiectasias, reticular veins), uncomplicated varicose veins with or without venous reflux, or longstanding venous insufficiency (ie, skin changes, venous ulceration)."

Finally, per Scovell, S. & Alquire, P. (2018), "Chronic venous disease refers to a wide spectrum of morphologic (ie, venous dilation) and/or functional abnormalities (eg, venous reflux) of long duration. Vein-related problems may or may not be symptomatic and include a wide range of clinical signs that vary from minimal superficial venous dilation to chronic skin changes with ulceration Inadequate muscle pump function, incompetent venous valves (reflux), and venous thrombosis or obstruction are causes of elevated venous pressure (venous hypertension), which initiates a sequence of anatomic, physiologic, and histologic changes leading to vein dilation, skin changes, or skin ulceration. The factors that determine whether a given patient will progress from mild to more severe disease are largely unknown."     
                                               
The requested services are not likely to be more beneficial than any of the standard treatment/procedures for the patient.

The carrier's denial of medical procedure 37785LT x 4 should be upheld.