Appeal type: Experimental/Investigational
Decision: Upheld

Physician #1:  The patient is a 52-year-old female who has had telangiectasias and recurrent varices, which initially started when she was 24, and was treated with sclerotherapy. She has now experienced a recurrence with mild swelling and heaviness symptoms. The patients duplex exam did not show any greater saphenous vein (GSV) reflux in either leg, only a localized area of reflux on the left leg, which it seems is not intended to be addressed with the proposed treatment. At issue is whether sclerotherapy with topical laser ablation as suggested by the patients physician is likely to be more beneficial than standard therapy.Telangiectasias and small reticular veins are generally considered to be cosmetic, though they sometimes may cause symptoms as has occurred in this case. According to Medicare guidelines, the generally accepted indication for sclerotherapy of small varices is the persistence of pain despite medical therapy or in conjunction with saphenous vein stripping or ablation in those with reflux. In this case the patient has reticular veins less than 1mm and telangiectasias; these are not clinical indications for sclerotherapy. Furthermore, the likelihood of recurrence of these veins and telangiectasias with the proposed treatment is very high; the most effective treatment method is compression stocking use, with or without laser/sclerotherapy.Based upon the information set forth above, I have determined that the requested procedures are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician #2:  The patient is a woman with telangiectasias (spider veins) and reticular veins of both legs.  Over the last four to five months she has had symptoms of itching of both legs, as well as pain and tenderness of the left leg.  She has tried compression stockings for over one year.  Physical examination documents the presence of telangiectasias and reticular veins of both legs.  There is no documentation of larger varicose veins.  A venous duplex exam showed no saphenofemoral reflux.  It did show reflux in a Boyds level perforator on the left.  The provider requests authorization to perform sclerotherapy and topical laser therapy on both legs.  The number and size of the vessels to be treated are not specified.  The Health Plan denied this request indicating that telangiectasias are considered asymptomatic, and isolated sclerotherapy without associated ligation and stripping of the saphenous vein is investigational.  There is general agreement within the vascular surgery community that sclerotherapy of telangiectasias is considered cosmetic in nature as telangiectasias are generally considered to be asymptomatic. It is assumed that treatment of telangiectasias by any method would be considered cosmetic.  Therefore, sclerotherapy and topical laser therapy of telangiectasias of both legs is not medically necessary.Regarding treatment of reticular veins and larger varicose veins, this patient would potentially be a candidate for sclerotherapy and topical laser ablation of the left leg.  The right leg would not warrant treatment, as significant symptoms are not documented. The left leg is documented to have significant pain and tenderness. Although sclerotherapy to symptomatic varicose veins of the left leg would be within the standard of care, it is clear that the provider plans to treat telangiectasias of the left leg as well.  As these vessels are cosmetic in nature the use of sclerotherapy on these vessels would be considered cosmetic. If an alternate treatment plan is submitted indicating that only larger varicose veins and not telangiectasias are to be treated, then the left leg sclerotherapy would be medically reasonable and appropriate and within the standard of care of the vascular community. However, based upon the information available at this time, I have determined that the requested procedures are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld at this time.Physician #3:  The patient is a 52-year-old female with symptomatic varicose veins and spider telangiectasias. Duplex reveals no reflux of either saphenous system. The patient falls within CEAP classification C1. Her provider has recommended treatment with sclerotherapy and topical laser ablation. The Health Plan has denied authorization and coverage for the proposed treatment.Based on the submitted medical records the patient has symptomatic spider veins with competent deep venous system and saphenous venous systems. She is classified as C1, (i.e., telangiectasias or reticular veins less than 3 mm). Review of the medical literature reveals no clear Level I evidence supporting the treatment regimen prescribed for the patient. Furthermore, topical laser ablation and sclerotherapy for spider veins are considered cosmetic procedures and are not medically warranted. Therefore, I have determined that the requested procedures are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.