Appeal type: Medical necessity
Decision: Overturned

Diagnosis: great saphenous vein reflux.
Treatment: Endoluminal Ablation of Varicose Veins.
The insurer denied: Endoluminal Ablation of Varicose Veins.
The determination is: Overturned.

The patient is a female who was evaluated with complaints of "achiness, heaviness, and fatigue in both lower extremities." The office note reports that "intermittently, she has worn compression with no improvement." The patient previously underwent segmental ablation of the right great saphenous vein 5 years ago. A bilateral lower extremity venous duplex was performed and showed a 12-centimeter (cm) segment of right greater saphenous vein (GSV) from the saphenofemoral junction to proximal thigh with reflux and the left GSV demonstrated reflux from the saphenofemoral junction to the mid-calf. Bilateral great saphenous venous ablation was recommended.
The request for endoluminal ablation of the bilateral great saphenous veins was denied by the patient's health plan based on the fact that the office note provided did not document that the patient suffered severe symptoms that interfered with her daily life or work and that there was insufficient documentation that conservative treatment such as leg elevation or exercise or over-the-counter pain meds had failed to alleviate the symptoms. The health plan's denial further points out that it is unclear how long that patient has tried conservative treatment by wearing compression stockings.

The health plan's determination is overturned.

Based on the literature endoluminal ablation of the great saphenous veins bilaterally is medically necessary for this patient.
Based on the office note provided the patient is described as having Clinical Class, Etiology, Anatomical, Pathophysiology (CEAP) score of C2 symptomatic varicose veins of both lower extremities. The office note is lacking in detail regarding specifics of the patient's symptoms and how they may or may not interfere with her daily activities and is also lacking in specifics regarding conservative treatments tried and their results. The provider should have included these specifics in the medical documents to better argue to the health plan for the need for endoluminal ablation, but regardless, the patient is documented as having symptomatic C2 bilateral varicose veins with bilateral great saphenous vein reflux involving the saphenofemoral junction bilaterally that is amenable to endoluminal venous ablation. A 2020 consensus expert statement by Masuda et al. found that it is appropriate to perform GSV ablation for patients with symptomatic C2 disease in the setting of GSV axial reflux. The severity of these symptoms are not mentioned in the consensus statement and given that the patient has symptoms with documented GSV reflux bilaterally indicates that GSV ablation is warranted bilaterally.
With regard to the patient must have failed conservative treatment for a certain period of time prior to endoluminal ablation being deemed appropriate per the health plan, the 2011 clinical practice guidelines for the Society of Vascular Surgery and the American Venous Forum advised that "compression therapy is not recommended as the primary treatment if the patient is a candidate for saphenous vein ablation (GRADE 1B)." The 2016 Practice Guidelines of the American College of Phlebology recommended that "when patients have a correctable source of reflux, definitive treatment should be offered unless it is contraindicated or unwarranted (GRADE 1A)," and "recommend against compression therapy as a prerequisite therapy for symptomatic venous reflux disease (GRADE 1A)." Both of these documents indicate that a period of failed conservative treatment prior to health plan approval of endoluminal ablation is unsupported by the literature.