Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve stab phlebectomy of varicose veins. We decided that the Plan does 
not have to pre-approve injection of sclerosant.  
 
You asked the Plan to pre-approve stab phlebectomy of varicose veins (37765, 37766) and injection of 
sclerosant (36471). You say that this is medically necessary. The Plan says that there is no documentation that 
that tributary or perforator veins measure greater than 4 mm in diameter and reflux is still present. Also, there is 
no documentation that the enrollee has participated in 6 weeks of conservative treatment. 
 
We decided that the Plan has to pre-approve stab phlebectomy of varicose veins.  
 
The Plan follows Medicare rules. Medicare rules say that stab phlebectomy can be covered when specific 
criteria are met.  
 
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 the item/service at issue. Our reviewer 
says that the service is medically necessary. Our physician reviewer found there is satisfactory documentation 
that the proximal thigh varicosities are well over 4mm in diameter and this area is not in the territory of the 
treatable saphenous reflux. Saphenous vein ablation has no role in the treatment of these large proximal thigh 
varicosities and there is satisfactory documentation that the significant symptoms persist despite conservative 
efforts. As all criteria have been met, and the proposed procedure is both reasonable and medically necessary, 
recommend coverage of phlebectomy of the large neovascular varicosities in the proximal thigh. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the item/service at issue have been met. Therefore, we decided that the Plan has 
to pre-approve stab phlebectomy of varicose veins.  
 
We also decided that the Plan does not have to pre-approve injection of sclerosant. 
 
The Plan follows Medicare rules. Medicare rules say that sclerotherapy can be covered when specific criteria 
are met.  
 
   
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 the item/service at issue. Our reviewer 
says that the enrollee does not meet criteria for coverage of sclerotherapy. Our physician reviewer found that 
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. As the patient has not yet 
undergone saphenous vein reflux treatment, the above criteria have not been met. The health 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 the item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pre-approve injection of sclerosant. 
 
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.