Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Chronic Venous Insufficiency.

Treatment procedure code 36475, endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein of the right and left great saphenous vein and right and left small saphenous vein (4 units)

The insurer denied coverage for procedure code 36475, endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein of the right and left great saphenous vein and right and left small saphenous vein (4 units)

The denial is Modified.

This patient has been recommended to undergo endovenous ablation due to chronic venous insufficiency.  She was seen for evaluation of the venous system.  The documentation indicated there was evidence of reflux bilaterally within the common femoral vein (CFV) and greater saphenous vein (GSV).  Venous insufficiency was noted within the right small saphenous vein (SSV) and left perforator venin (PV) however was not noted within the left SSV and right PV.  There were moderately dilated perforator veins noted within the mid-thigh and the perforator vein had 0.57 (centimeters) cm diameter and displayed 3.5 seconds of reflux.  The documentation indicated that she was seen for a follow-up and to review test results.  The documentation indicated she had complaints of burning pain and itching to both lower extremities.  The documentation indicated she had ongoing symptoms despite continued leg elevation.  The physical examination revealed large varicose veins noted on both medial aspects of the right and left as well as the lateral aspect.  The venous ulcer that she previously had was totally closed.  The physician detailed given the continued symptoms she should undergo venous ablation therapy.

Based on the clinical information provided, the patient meets criteria for endovenous laser ablation of the bilateral greater saphenous veins and right small saphenous vein (3 units).   The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

There was no evidence of venous insufficiency in the left small saphenous vein.  Thus, the patient did not require endovenous laser ablation of the left small saphenous vein based on established consensus criteria.  The health plan acted reasonably with sound medical judgment.  

The patient failed conservative management of varicose veins and venous insufficiency with compression stockings and demonstrated evidence of clinically significant superficial venous insufficiency by ultrasound as well as history and physical with documented limitations on activities of daily living.  Endovenous laser ablation of varicose veins has been shown to improve patient's quality of life and clinical course following the therapy in multiple studies and consensus guidelines.  

The insurer's denial of coverage for the procedure code 36475, endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency should be modified. Endovenous laser ablation of the bilateral greater saphenous veins and right small saphenous vein (3 units) should be reversed.  Denial of the endovenous laser ablation of the left small saphenous vein should be upheld.