Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Varicose Veins.
Treatment: Right Ambulatory Phlebectomy (Outpatient Procedure, 37766RTx1, 37765RTx1, 37785RTx1 and 37799RTx1), Pre-service.
The insurer denied the Right Ambulatory Phlebectomy (Outpatient Procedure, 37766RTx1, 37765RTx1, 37785RTx1 and 37799RTx1), Pre-service.
The denial is upheld. 

The patient is a female.  The attending physician (AP) has proposed right leg phlebectomy for this patient who presented with right leg swelling and pain for one month. The patient has already undergone bilateral iliac vein stenting in the recent past for bilateral leg swelling, leading to improvement of her symptoms. However, the symptoms have recurred on the right. 

Exam showed "scattered small varicosities throughout the right lower extremity with mild swelling". Reflux testing showed focal saphenofemoral junction (SFJ) reflux without greater saphenous vein (GSV) reflux. The iliac vein stents were patent.

Coverage was denied on the basis that the phlebectomy can only be approved when done in conjunction with saphenous ablation.

No, the proposed Right Ambulatory Phlebectomy (Outpatient Procedure, 37766RTx1, 37765RTx1, 37785RTx1 and 37799RTx1) is not medically necessary.
The attending physician has proposed right leg phlebectomy for this patient who presented with right leg swelling and pain for one month. The patient has already undergone bilateral iliac vein stenting in the recent past for bilateral leg swelling, leading to improvement of her symptoms. However, the symptoms have recurred on the right. Exam showed "scattered small varicosities throughout the right lower extremity with mild swelling". Reflux testing showed focal saphenofemoral junction (SFJ) reflux without greater saphenous vein reflux. The iliac vein stents were patent.

Coverage was denied on the basis that the phlebectomy can only be approved when done in conjunction with saphenous ablation.

In order to evaluate the medical necessity of the service, widely accepted standards have been applied. [1-3] Under these standards, phlebectomy is appropriate when:
a-	There is no axial saphenous reflux, or any associated axial reflux has been treated. If axial reflux has been treated, a sufficient waiting period (usually four to six weeks minimum) should elapse to allow for evaluation of the patient's residual leg symptoms.
b-	The patient has symptoms of venous insufficiency severe enough to interfere with normal function.
c-	The patient's varicose veins are large enough to account for the symptoms.
d-	The patient has failed a trial of medical grade compression stockings.

Requirement (a) has been met. The patient's venous reflux study does not show clinically significant axial reflux. She has only focal reflux at the saphenofemoral junction.

Requirement (b) has not been met. The office notes describe right leg swelling and pain, but the notes do no describe the impact on the patient's function.

Requirement (c) has not been met. The physician has documented small, scattered varicose veins of the right leg. Varicose veins of this type are not likely to account for the patient's symptoms.

Requirement (d) has been met. The office note states that the patient has been using compression stockings regularly with no relief of symptoms.

Therefore, in summary, the patient does not meet published, well accepted criteria for performance of phlebectomy.

Coverage was denied on the basis that the phlebectomy can only be approved when done in conjunction with saphenous ablation. This is not a valid basis of denial because studies have demonstrated the value of "isolated" phlebectomy, i.e., phlebectomy done in the absence of axial reflux [2]. However this denial is upheld for reasons described above.

However, coverage was denied on the basis that the phlebectomy can only be approved when done in conjunction with saphenous ablation. This is not a valid basis of denial because studies have demonstrated the value of "isolated" phlebectomy, i.e., phlebectomy done in the absence of axial reflux [2]. 

However, this denial is upheld for reasons described above.