Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve treatment for the left leg. We decided that the Plan does not have 
to pre-approve treatment of the right leg or additional treatments of the left leg until reassessment following 
initial treatment.  
 
You asked the Plan to pre-approve treatment of varicose veins of the lower extremities. You say that it is 
medically necessary. The Plan says that it is not medically necessary. 
 
We decided that the Plan has to pre-approve treatment for the left leg.  
 
The Plan follows Medicare rules. Medicare rules say that the treatments of the tributary veins will be 
considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins 
are greater than 4 mm 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 pay for treatment of varicose veins of the lower 
extremity. Our reviewer says that treatment of the left leg is medically necessary. Our physician reviewer found 
the documentation suggests that the left posterior accessory saphenous vein may be most associated with the 
patients symptomatic varicosities and is one of the territories requested for treatment. Therefore, recommend 
coverage of left posterior accessory saphenous vein ablation as criteria are all met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of treatment of varicose veins of the lower extremity have been met. Therefore, we 
decided that the Plan has to pre-approve treatment for the left leg. 
 
We also decided that the Plan does not have to pre-approve treatment of the right leg or additional 
treatments of the left leg until reassessment following initial treatment. 
 
The Plan follows Medicare rules. Medicare rules say that the treatments of the tributary veins will be 
considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater than 4 mm 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 pay for additional treatments until reassessment 
following initial treatment. Our reviewer says that these services are not medically necessary. Our physician 
reviewer found criteria are not met for treatment of the right leg as it is documented that the right leg is less 
symptomatic and documentation of symptoms on the left barely meet the level of activity or mobility limiting. 
Criteria are not met for multiple procedures on the left leg as it has not yet been documented that initial 
treatment has failed to improve the enrollees symptoms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of treatment of the right leg and additional treatments until reassessment following 
initial treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment 
of the right leg or additional treatments of the left leg until reassessment following initial treatment. 
 
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.