Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve endovenous ablation of the left great saphenous vein (36475). 
We decided that the Plan does not have to pre-approve tributary treatment including stab phlebectomy (37765, 
37766).  
 
You asked the Plan to pre-approve treatment for varicose veins.. You say that these services are medically 
necessary. The Plan says that coverage criteria has not been met. 
 
We decided that the Plan has to pre-approve endovenous ablation of the left great saphenous vein 
(36475).   
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 endovenous ablation of the left great 
saphenous vein. Our reviewer says that endovenous ablation of the left great saphenous vein is medically 
necessary. Tributary treatment including stab phlebectomy is not medically necessary. Our physician reviewer 
found that there is satisfactory documentation of symptom severity, resistance to conservative efforts, 
significant reflux and dilatation of the left great saphenous vein, and symptoms attributable to her venous 
insufficiency. There is also satisfactory documentation that there is edema involving the lower extremities 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation of the left great saphenous vein have been met. Therefore, 
we decided that the Plan has to pre-approve endovenous ablation of the left great saphenous vein (36475).  
 
We also decided that the Plan does not have to pre-approve tributary treatment including stab 
phlebectomy (37765, 37766). 
 
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 tributary treatment including stab 
phlebectomy. Our reviewer says that tributary treatment including stab phlebectomy is not medically necessary. 
Our physician reviewer found that coverage criteria requires that the patient first have the truncal reflux treated, 
and has 4 mm or greater diameter tributaries that remain significantly symptomatic despite conservative 
treatment for at least 6 weeks after the truncal reflux is treated. These conditions are not met based on the 
records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tributary treatment including stab phlebectomy have not been met. Therefore, 
we decided that the Plan does not have to pre-approve tributary treatment including stab phlebectomy (37765, 
37766). 
 
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.