Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that the treatment for Symptomatic Chronic Venous Insufficiency or Varicose Veins (VV), in the absence of bleeding, phlebitis or skin necrosis, may be covered as medically necessary with: 1. A documented 3-month trial of conservative therapy including graduated compression stockings with a minimum of (12-18 mmHg), weight reduction to BMI less than 35, therapeutic leg elevation, and an exercise program of calf muscle pumping activity with compression of the involved veins, which results in limited alteration/improvement of symptoms or findings without satisfactory endpoint, and 2. Duplex venous studies of the involved lower extremity(s), mapping size and course of the greater and lesser saphenous vein and prominent tributaries and demonstrating the: -Presence and Patency of the Deep Venous System. -Absence of Deep Venous Thrombosis, and -Documented Incompetence (reflux greater than 500msec) of the Valves of the Saphenous, Perforator or Deep venous systems consistent with the patient's symptoms and findings. You can find this rule in Local Coverage Determination (LCD): Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities (L34924) - Effective November 14, 2019. The rules say that treatment of Varicose Veins and Venous Stasis Sequella of the Lower Extremities is covered as medically necessary when etiologic for one or more of the following conditions: -Hemorrhage from ruptured or ulcerated superficial varix requiring medical or surgical intervention and/or compensation for blood loss anemia or documented aneurysmal formation with skin and vein wall fusion (pre-rupture). -Recurrent superficial phlebitis in dilated incompetent veins or clusters. -Progressive skin and soft tissue changes which include darkening and lichenification, inflammatory cellulitis and dermatitis, skin and fat necrosis and/or ulceration at the site of documented chronic venous distention with valvular incompetence. Lower extremity edema without skin compromise is not considered a medically necessary indication for treatment of varicosities or venous valvular incompetence. -In the absence of clinical signs and symptoms (e.g. bleeding, thrombosis, ulceration, aneurysm formation, skin changes), irregular and protrusive saphenous veins with documented diameters of greater than 9.6 mm, or prominent protrusive clusters or tributaries of the greater or lesser saphenous veins, or clusters overlying perforator veins superficial to the muscle compartment fascia with a diameter greater than 4.9mm, which are refractory to a 3 month trial of conservative therapy and graduated compression stockings and with symptoms consistent with venous hypertension. You can find this rule in Local Coverage Determination (LCD): Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities (L34924) - Effective November 14, 2019.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.