Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve sclerotherapy and phlebectomy of the right leg. We decided that the Plan does not have to pre-approve sclerotherapy and phlebectomy of the left leg.

You asked the Plan to pre-approve sclerotherapy and phlebectomy of the right leg. You say that these services are medically necessary for treating the enrollee's medical condition. The Plan says that the criteria for coverage have not been met.

We decided that the Plan has to pre-approve sclerotherapy and phlebectomy of the right leg.

The Plan follows Medicare rules. Medicare rules say that these services are subject to the criteria listed in the Medicare rules section. 

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 sclerotherapy and phlebectomy of the right leg. Our reviewer says that the requested procedures on the right leg is medically necessary and reasonable. Our physician reviewer found that with respect to the right leg, the photos demonstrate extensive varicose veins that may not be in the direct territory of the greater saphenous vein and, if can be performed the same time, would be reasonable to address at the same time as the procedures already approved by the Plan. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sclerotherapy and phlebectomy of the right leg have been met. Therefore, we decided that the Plan has to pre-approve sclerotherapy and phlebectomy of the right leg.

We also decided that the Plan does not have to pre-approve sclerotherapy and phlebectomy of the left leg.

The Plan follows Medicare rules. Medicare rules say that these services are subject to the criteria listed in the Medicare rules section. 

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 sclerotherapy and phlebectomy of the left leg. Our reviewer says that the requested procedures on the left leg are not medically necessary.

Our physician reviewer found that the documentation is not sufficient to support additional procedures on the left beyond that which is covered. After the covered procedures are performed, reevaluation can be completed to see if additional procedures are necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sclerotherapy and phlebectomy of the left leg have not been met. Therefore, we decided that the Plan does not have to pre-approve sclerotherapy and phlebectomy of the left leg.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.