Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe peripheral vascular disease. 
Treatment:  ReVascular, CPT (current procedural terminology) code: 37238; 1 Unit(s). 
The insurer denied coverage for ReVascular, CPT (current procedural terminology) code: 37238; 1 Unit(s). 
The denial is upheld. 

The Vascular Surgeon is appealing. In an appeal letter, the surgeon stated that the patient suffers from severe peripheral vascular disease (PVD), hypertension (HTN), and iliac vein stenosis. The patient has bilateral leg swelling. The patient's daily activities are limited due to severe venous insufficiency. The patient cannot sit or stand for long periods of time without significant pain in the lower extremity varicose veins. The patient would benefit from bilateral venogram/intravascular ultrasound (IVUS) with possible angioplasty and possible stent. The treatment would significantly reduce the patient's symptoms. 

7 years ago, this patient has had previous inferior vena cava (IVC) and iliac venous stenting. A letter indicated the patient had previous Pelvic Venous Stenting. 

A duplex ultrasound showed previous stenting was patent with good variation and documented significant bilateral superficial venous reflux disease. The IVC and external iliac vein (EIV) duplex showed patent stents. 

The request is for ReVascular, current procedural terminology (CPT) code 37238, one (1) unit, which is under review. 

By recent Venous Duplex Doppler testing there is no documentation that this patient's pelvic stents are not patent (CPT 37238). This patient at this time appears to have significant superficial venous reflux disease possibly causing his present venous related symptoms. Per Patel, S. K., & Surowiec, S. M. (2022), "Venous Insufficiency. Patients with chronic venous insufficiency should be treated based on the severity and nature of the disease. The treatment goals include reducing discomfort and edema, stabilizing skin appearance, removing painful varicose veins and healing ulcers. Most patients should initially be treated conservatively with leg elevation, exercise (which improves calf muscle pump), weight management, and compression therapy. Compression therapy is long term and only benefits patients who remain compliant. Superficial vein reflux can be managed with foam sclerotherapy, endovenous thermal ablation, or stripping. Deep vein reflux may be treated with valve reconstruction or valve transplant. Perforator reflux can either be managed with sclerotherapy, endovenous thermal ablation, or with subfascial endoscopic perforator surgery (SEPS). It should be noted, however, that compression therapy regimens that are adhered to are highly effective in treating all forms of venous pathophysiology." 

Per Scovell, S., (2022), "Radiofrequency ablation (RFA) is a minimally invasive percutaneous technique using thermal energy to ablate incompetent veins. The device is used primarily to treat insufficiency of the axial veins (i.e., great, small, accessory saphenous veins), but perforator veins can also be treated with a specialized radiofrequency stylet." 

Per Ihnat, D., (2021), "Endovenous laser ablation (EVLA) is a percutaneous technique that uses laser energy to ablate incompetent superficial veins. The axial veins are the primary target for this therapy and include the great saphenous vein (GSV), small saphenous vein (SSV), and accessory saphenous veins (ASVs)." 

Finally as per Up to Date "Using stents designed specifically for the venous system is of paramount importance in treating venous occlusive disease. Patency rates are overall high for venous stenting, particularly for non-thrombotic lesions."  As noted above, no evidence of venous occlusive disease was found.                                                 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for ReVascular, current procedural terminology (CPT) code 37238, 1-unit services is not substantiated.