Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Leg pain
Treatment: 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 (e.g., great saphenous vein, accessory saphenous vein) and other related codes.
The insurer denied coverage for 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 (e.g., great saphenous vein, accessory saphenous vein) and other related codes.
The denial is overturned.

This is a patient with a history of hypertension, hyperlipidemia, diabetes mellitus, and questionable cardiomyopathy after hospitalization for 18 days with COVID.  A venous insufficiency report was noted. The right great saphenous vein had 800 ms (milliseconds) of reflux. The left great saphenous vein had 920 ms of reflux.  The left small saphenous vein had 680 ms of reflux. The right small saphenous vein at 740 ms of reflux. There was spontaneous, phasic, augmented flow.  All vessels were compressible and a endoluminal thrombus was seen. The patient was seen with complaints of shortness of breath, chest pressure, and decreased walking capacity. She was limited to 2-3 blocks due to shortness of breath and chest pressure. She complained of leg pain associated with swelling and painful varicosities despite compression stockings for the past year. Her leg pain was associated with fatigue, cramping, and heaviness of the bilateral lower extremities. A recommendation was noted for arterial ultrasound to evaluate for peripheral arterial disease. The patient has significant venous insufficiency with prolonged reflux time and long segment of the superficial venous system. The patient complained of significant pain and swelling that interfered with daily activity. She had utilized prescribed graduated compression stockings for more than 6 months. Symptoms have not been successfully managed due to intolerance or infective symptom relief.  

Per the MCG (Milliman Care Guidelines) sclerotherapy for leg veins is recommended for bleeding or ruptured superficial varicose veins, recurrent or residual symptomatic superficial varicosities after vein stripping or ablation, skin ulcer with surrounding large superficial varices, not associated with saphenofemoral valve incompetence, and for symptomatic superficial varices.  Per Ahadiat et. al. (2018), endovenous thermal ablation is popular treatment for varicose veins of the greater saphenous vein. Two common techniques of thermal ablation include endovenous laser therapy and radiofrequency ablation.  Both treatments have been found to be highly efficacious. In this case, the patient complained of significant pain and swelling that interfered with daily activity.  She had utilized prescribed graduated compression stockings for more than 6 months. Symptoms have not been successfully managed due to intolerance or infective symptom relief.  

The insurer's denial of coverage for 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 (e.g., great saphenous vein, accessory saphenous vein) and other related codes is overturned. Medical Necessity is substantiated.