Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve sclerotherapy of the right lower extremity. We also decided that 
the Plan does not have to pre-approve sclerotherapy of the left lower extremity.  
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan says that the enrollee does not meet Medicare criteria for coverage of these services.  
 
We decided that the Plan has to pre-approve sclerotherapy of the right lower extremity.  
Specifically, the Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be 
considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins 
are > 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 pre-approve this service. Our reviewer says 
that sclerotherapy of the right lower extremity is medically necessary. Our physician reviewer found that the 
enrollee has significant symptoms in that she has what appears to be a venous stasis ulcer and there is 
documentation of palpable pedal pulses. Photos are provided that, for the purpose of this review, satisfies the 
size criteria (>4mm) for tributary varicosities. We looked at this physician's review, the file, and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of this service have been met. 
Therefore, we decided that the Plan has to pre-approve sclerotherapy of the right lower extremity.  
 
We also decided that the Plan does not have to pre-approve sclerotherapy of the left lower extremity. 
Specifically, the Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be 
considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins 
are > 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 pre-approve this service. Our reviewer says 
that the requested service is not medically necessary. Our physician reviewer found that the documentation 
does not suggest symptoms on the left extremity that meets coverage criteria or warrants treatment. We looked 
at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-
approve sclerotherapy of the left lower extremity. 
 
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.