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 stab phlebectomy.  
 
You asked the Plan to pre-approve endovenous ablation (36475) and stab phlebectomy (37765).. You say that 
the services are medically necessary. The Plan says that the enrollee does not meet coverage criteria. 
 
We decided that the Plan has to pre-approve endovenous ablation.  
 
The Plan follows Medicare rules. 
 
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 enrollee meets coverage criteria for endovenous ablation. Our physician reviewer found there is 
satisfactory documentation of absence of deep vein thrombosis (DVT), reflux in the segment of saphenous vein 
to be treated as well as satisfactory documentation of symptoms severe enough to interfere with activities of 
daily living despite conservative efforts including the use of medical grade compression stockings. There is 
documentation of pedal pulses. While there is documentation of tortuosity at a portion of the great saphenous 
vein, a plan is articulated to mitigate this and therefore there is no suggestion that there is significant tortuosity 
in the veins planned for treatment. The vein size is appropriate and meets criteria. As all criteria for saphenous 
vein ablation are met, recommend coverage.  
 
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 stab phlebectomy. 
 
The Plan follows Medicare rules. 
 
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 stab phlebectomy. Our reviewer says 
that the enrollee does not meet coverage criteria for stab phlebectomy. Our physician reviewer found that for 
tributary treatment such as stab phlebectomy 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 criterion is met). As the 
enrollee 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 stab phlebectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve stab phlebectomy. 
 
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.