Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve endovenous ablation. We decided that the Plan does not have to 
pre-approve sclerotherapy .  
 
You asked the Plan to pre-approve sclerotherapy (36470) and endovenous ablation (36482). You say that the 
enrollee's pain and swelling interfere with activities of daily living.  The Plan says that records state the enrollee has mild edema. Additionally, the documentation indicates the right-side veins are under four 
millimeters and saphenous reflux is present.  
 
We decided that the Plan has to pre-approve endovenous ablation.  
 
The Plan follows Medicare rules. Medicare rules say that the treatments to eliminate the saphenous vein reflux 
will be considered medically necessary if the patient remains symptomatic after a six-week trial of conservative 
therapy and has reflux in a saphenous vein. 
 
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. Our reviewer says 
that the endovenous ablation is medically reasonable and necessary. Our physician reviewer found that the 
documentation of enrollees symptoms suggests that the enrollee is improved status post left GSV ablation with 
some residual varicosities and has right sided GSV reflux with associated symptoms that continue despite 
compression stockings for more than 3 months. There are portions of the medical record that suggest the 
symptoms are lifestyle limiting and the photos provide satisfactory documentation of significant edema in the 
territory to be addressed. There is documentation of palpable pedal pulses and significant reflux in portions of 
the right great saphenous vein without DVT. Therefore, all criteria are met for right great saphenous vein 
ablation.  
 
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 have been met. Therefore, we decided that the Plan has to 
pre-approve endovenous ablation.  
 
We also decided that the Plan does not have to pre-approve sclerotherapy . 
 
The Plan follows Medicare rules. Medicare rules say that the treatments of the tributary veins with 
sclerotherapy will be considered medically necessary if saphenous reflux is not present or already successfully 
eliminated, the veins are greater than 4 millimeters in diameter and if the patient remains symptomatic after a 
six-week trial of conservative therapy.   
 
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. Our reviewer says that 
the criteria for sclerotherapy have not been met. Our physician reviewer found that there is inadequate 
documentation that the residual varicose veins on the left are significantly symptomatic. Additionally, with 
respect to sclerotherapy on the right, for tributary treatment such as sclerotherapy to be considered medically 
necessary per coverage criteria, there needs to be persistent significant symptoms following successful 
treatment of truncal (saphenous) reflux with these symptoms existing more than 6 weeks after the reflux was 
treated and despite conservative efforts. Additionally, the veins to be treated need to be at least 4 mm in 
diameter (this condition is not met). As the enrollee has not yet undergone saphenous vein reflux treatment, the 
above criteria have not been met. The Plan does not provide for simultaneous saphenous reflux treatment and 
tributary treatment. A rationale for this is that many patients experience satisfactory relief with the truncal 
intervention alone. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy . 
 
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.