Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection of non-compounded foam sclerosant with 
ultrasound compression maneuvers to guide dispersion of the injectate (36465, 1 unit) and an injection of non-
compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate 
(36466, 4 units). 
 
You asked the Plan to pre-approve injections. You say that the enrollee has chronic venous insufficiency or 
varicose veins. She complained of continued pain, fatigue and discomfort in her lower extremities and her 
symptoms persistent despite conservative therapy. The Plan denied your request. The Plan says the medical 
record indicates the enrollee continues to have symptoms despite leg elevation, compression stockings and 
prescription medications. An ultrasound shows dilation over 3 mm and reflux of five of the requested veins 
with no DVT. However, one of the requested tributary veins did not meet criteria for this procedure. The 
posterior calf tributary on the right leg was not over 3 mm in diameter and therefore, did not meet criteria for 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found coverage criteria require that the symptoms be attributable to the varicose veins in question and 
are severe enough to interfere with activities of daily living despite efforts at conservative treatment.  It is not 
possible to attribute the enrollee's leg pain to venous disease without assessment of arterial perfusion.  In 
particular, the appropriateness and medical necessity of ablating both her great saphenous veins without an 
assessment of arterial perfusion cannot be supported. It is also not clear from the documentation that the 
enrollee is having lifestyle limiting pain. Additionally, reflux in the left great saphenous vein has not been 
satisfactorily documented. Furthermore, by requesting coverage of codes 36465 or 36466 the provider is 
requesting coverage of Varithena treatment to multiple truncal veins (saphenous or accessory saphenous veins) 
however, the duplex only demonstrates an isolated segment of reflux in only one saphenous vein.  The codes 
requested by the provider cannot be used for treatment of tributary veins. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an injection of non-compounded foam sclerosant with ultrasound compression maneuvers to 
guide dispersion of the injectate (36465, 1 unit) and an injection of non-compounded foam sclerosant with 
ultrasound compression maneuvers to guide dispersion of the injectate (36466, 4 units).