Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve bilateral endovenous ablation therapy. We decided that the Plan 
does not have to pre-approve small saphenous vein treatment with Varithena and sclerotherapy.  
 
You asked the Plan to pre-approve endovenous ablation therapy (36478 x 2), endovenous ablation with 
Varithena (36465), and sclerotherapy (36471). You say that the enrollee has tried compression stockings for 
over a year after doing sclerotherapy several years ago. You say that the enrollee has recurrent superficial 
thrombophlebitis. The Plan says that the enrollee does not have any qualifying symptoms. The Plan also says 
that sclerotherapy is not covered when saphenous reflux is present. 
 
We decided that the Plan has to pre-approve bilateral endovenous ablation therapy.  
 
The Plan follows Medicare rules. Medicare rules say that the treatments to eliminate the saphenous vein reflux 
will be considered medically necessary if the patient remains symptomatic after a six-week trial of conservative 
therapy and has reflux in a saphenous vein. 
 
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 bilateral endovenous ablation therapy. 
Our reviewer says that the requested bilateral great saphenous vein ablation is medically necessary. Our 
physician reviewer found there is satisfactory documentation of pain/symptoms interfering with enrollees 
quality of life and, by now, has had the stockings for well over 6 weeks. There is documentation of severe 
reflux in the great saphenous veins bilaterally and absence of DVT. There is documentation of pedal pulses 
bilaterally.  Therefore, the reviewer found that the bilateral great saphenous vein ablation is medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral endovenous ablation therapy have been met. Therefore, we decided 
that the Plan has to pre-approve bilateral endovenous ablation therapy.  
 
We also decided that the Plan does not have to pre-approve small saphenous vein treatment with 
Varithena and sclerotherapy. 
 
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. 
 
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 small saphenous vein treatment with 
Varithena and sclerotherapy. Our reviewer says that the requested small saphenous vein treatment with 
Varithena and sclerotherapy are not medically necessary. Our physician reviewer found that the documentation 
does not support the medical necessity criteria of small saphenous vein treatment with Varithena. The reviewer 
found that coverage criteria require the enrollee have significant symptoms attributable to the vein in question. 
The reviewer found that this cannot be assessed until the enrollee is evaluated a reasonable time following 
greater saphenous vein (GSV) ablation to see if symptoms have satisfactorily resolved. The reviewer also 
found that the documentation does not meet criteria with respect to sclerotherapy. The provided documentation 
does not support the enrollee has undergone saphenous vein reflux treatment. Therefore, the reviewer found 
that sclerotherapy is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of small saphenous vein treatment with Varithena and sclerotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve small saphenous vein treatment with 
Varithena and sclerotherapy. 
 
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.