Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins. 
Treatment: Vein procedure (right ambulatory phlebectomy) - procedure codes: 37766RTx1, 37765RTx1, 37785RTx1, and 37799x1. 

The insurer denied the Vein procedure (right ambulatory phlebectomy) - procedure codes: 37766RTx1, 37765RTx1, 37785RTx1, and 37799x1. 

The denial is overturned. 

This male presented with recurrent symptomatic right leg varicose veins. Current symptoms included leg heaviness, aching, and fatigue. He had noticed enlarging varicosities over the last several months. The symptoms interfere with his job as a cook, because he has to stand for long periods of time. He has tried and failed a trial of compression stockings. The patient's history is notable for prior right greater saphenous (GSV) ablation. Exam shows large varicose veins and well perfused legs. His reflux study shows successful prior greater sapehnous vein (GSV) ablation. There is no short saphenous or deep reflux and no deep venous thrombosis (DVT). 

Yes, the proposed veins procedure is medically necessary. 

The attending physician has proposed right leg phlebectomy for this patient who has minimal axial saphenous reflux. 

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. He has only focal reflux in separate segments of the greater saphenous vein. 

Requirement (b) has been met. The office notes show that the patient has symptoms of venous insufficiency severe enough to adversely affect normal function. The appeal letter corroborates the history reported in the office notes. 

Requirement (c) has been met. The physician has documented moderate to large right leg varicosities. 

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 meets published, well accepted criteria for performance of phlebectomy. 

Coverage was denied because the provider had not documented the status of the patient's arterial system. This is not a valid basis of denial because: 
1. The provider documented that the patient has well perfused feet, thus indicating adequate arterial perfusion; 
2. The patient has no reported symptoms to suggest arterial insufficiency; 
3. The patient is unlikely to have significant arterial insufficiency; 
4. Even if the patient had arterial insufficiency, he could still have symptomatic venous disease. Arterial insufficiency per se is not an accepted contraindication to treatment of symptomatic venous disease.