Appeal type: Practitioner Services
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, inclusive of all imaging guidance and 
monitoring; multiple incompetent truncal veins same leg (36466x2). 
 
You asked the Plan to pre-approve an injection. You say that the enrollee with chronic venous insufficiency 
and varicose veins in both lower extremities is status post bilateral vein stripping and her symptoms have 
improved but not completely with persistent symptoms of itchiness, heaviness, and burning sensation. The Plan 
denied your request. The Plan says the request for two units of a multiple vein code is in excess of the 
enrollee's medical need. 
 
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 an injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of hyperlipidemia, hypertension, atrial fibrillation, status post venous 
ablation of above knee great saphenous vein (GSV) who presented to the cardiology office for a follow up for 
venous insufficiency. She has minimal walking due to knee pain. Since the last visit, she reports swelling, 
heaviness, and pain in bilateral lower extremities. She has been using compression stockings with no 
improvement. Symptoms interfering with activities of daily living (ADLs)/quality of life. The physical exam is 
positive for leg swelling, heaviness, and pain in bilateral lower extremities, positive for joint pain, venous 
changes, bilateral varicosities. Per coverage guidelines, the veins targeted for treatment must be documented by 
their names, diameters, and backflow (reflux) on each date(s) of service in the medical records and the 
ultrasound duplex scan confirms presence of reflux of 500 milliseconds or more in the veins targeted to be 
treated. In this case, the records show that the provider plans to treat two target veins (left and right GSV). The 
plan approved the single vein treatment (36465). The provider submitted a request for additional multi-vein 
treatments (36466) without documenting names of the target veins. The review has determined that the enrollee 
does not meet criteria for approval of the injections. The injections are not medically 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 an injection 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, inclusive of all imaging guidance and monitoring; multiple incompetent 
truncal veins same leg (36466x2).