Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve sclerotherapy of telangiectasia and incompetent veins of the right 
leg. We decided that the Plan does not have to pre-approve sclerotherapy of telangiectasia and incompetent 
veins of the left leg.  
 
You asked the Plan to pre-approve bilateral sclerotherapy of telangiectasia and incompetent veins 
(code 36471). You say that the service is medically necessary and not cosmetic. The Plan says that 
sclerotherapy of telangiectasia and incompetent veins (code 36471) is cosmetic and does not meet the Medicare 
LCD coverage criteria. 
 
We decided that the Plan has to pre-approve sclerotherapy of telangiectasia and incompetent veins of the 
right leg.   
 
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 of telangiectasia and 
incompetent veins. Our reviewer says that sclerotherapy of telangiectasia and incompetent veins of the right leg 
is medically necessary. Our physician reviewer found that while the veins to be treated do not meet size criteria 
for coverage, the bleeding from the varicosities supersedes this criteria. In this case, treatment of the area where 
you bled satisfies the coverage criteria as symptomatic. It is noted by the provider that treatment of the bleeding 
area could be managed in 1 session. Recommend coverage of a single session of sclerotherapy to the area 
which you bled, believed to be the right proximal lateral calf. Otherwise, you do not meet criteria for treatment 
as it is not clear that your symptoms are coming from the spider veins and there is evidence to suggest that 
treatment of spider veins for pain is no better than placebo. Additionally, you do not meet size criteria for 
sclerotherapy in the absence of bleeding. In summary, recommend coverage of a single session of sclerotherapy 
to the right leg as detailed above.  
 
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 of telangiectasia and incompetent veins of the right leg have been 
met. Therefore, we decided that the Plan has to pre-approve sclerotherapy of telangiectasia and incompetent 
veins of the right leg.  
 
We also decided that the Plan does not have to pre-approve sclerotherapy of telangiectasia and incompetent 
veins of the left leg. 
 
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 of telangiectasia and 
incompetent veins. Our reviewer says that sclerotherapy of telangiectasia and incompetent veins of the left leg 
is not medically necessary. Our physician reviewer found that while the veins to be treated do not meet size 
criteria for coverage, the bleeding from the varicosities supersedes this criteria. In this case, treatment of the 
area where you bled satisfies the coverage criteria as symptomatic. Otherwise, you do not meet criteria for 
treatment as it is not clear that your symptoms are coming from the spider veins and there is evidence to 
suggest that treatment of spider veins for pain is no better than placebo. Additionally, you do not meet size 
criteria for sclerotherapy in the absence of bleeding. 
 
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 of telangiectasia and incompetent veins of the left leg have not 
been met. Therefore, we decided that the Plan does not have to pre-approve sclerotherapy of telangiectasia and 
incompetent veins 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.