Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins
Treatment: Radiology Services (including Ultrasound)
The insurer denied the Radiology Services (including Ultrasound)
The determination is overturned in part.

The patient presented with left leg symptomatic varicose veins. His main symptoms include: pain, edema and skin discoloration. The patient has attempted and failed conservative therapy with graded compression stockings without symptomatic relief. He has undergone prior saphenous vein closure. His provider has recommended endovenous ablation of the following veins: left anterior accessory great saphenous vein, left great saphenous vein in the calf, left perforator vein closure, right great saphenous vein ablation and right perforator vein closure. At issue is the medical necessity of endoluminal ablation of the varicose veins.

The procedures are medically necessary in part.

1) Endovenous radiofrequency ablation of the left anterior accessory great saphenous vein is medically necessary based on the peer reviewed literature.
2) Endovenous ablation of the right great saphenous vein is medically necessary based on the peer reviewed literature
3) Endovenous ablation of the right great saphenous vein in the calf is not medically necessary based on the peer reviewed literature.
4) Endovenous ablation of the right and left leg perforator veins is not medically necessary based on the peer reviewed literature.

The patient presented with bilateral lower extremity symptomatic varicose veins which are refractory to conservative therapy. He also presented with hyperpigmentation and signs of advanced chronic venous hypertension. The patient has attempted conservative therapy with graded compression stockings for several months without symptomatic relief. His main symptoms include:  aching, fatigue and swelling. The patient demonstrates reflux in multiple bilateral superficial axial veins.
Endovenous ablation of the left anterior accessory saphenous vein and the right great saphenous vein are the current standards of care treatment for patients with symptomatic varicose veins and saphenous vein reflux and for this particular patient. The most recent consensus guidelines for the Society for Vascular Surgery and the American Venous Forum support endovenous thermal ablation for this patient based on his clinical presentation. Endovenous ablation is supported by the peer reviewed literature including level 1 randomized evidence. Several current peer reviewed papers support the use of endovenous thermal ablation for patients with symptomatic varicose veins with excellent results.

Hamann and colleagues demonstrated excellent results with thermal ablation (radiofrequency and laser) in patients with symptomatic varicose veins. They wrote that the current treatment strategy for many patients with varicose veins is endovenous thermal ablation. The most common forms of this are endovenous laser ablation (EVLA) and radiofrequency ablation (RFA). However, at present there is no clear consensus on which of these treatments is superior. The objective of this study was to compare EVLA with two forms of RFA: direct RFA (dRFA; radiofrequency-induced thermotherapy) and indirect RFA (iRFA; VNUS ClosureFast TM). Patients with symptomatic great saphenous vein (GSV) incompetence were randomized to receive EVLA, dRFA or iRFA. Patients were followed up at 2 weeks, 6 and 12 months. The primary outcome was GSV occlusion rate. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) score and adverse events. Some 450 patients received the allocated treatment (EVLA, 148; dRFA, 152; iRFA, 150). The intention-to-treat analysis showed occlusion rates of 750 (95 per cent c.i. 680 to 820), 599 (521 to 677) and 813 (751 to 876) percent respectively after 1 year.

However, the additional ablation procedures of the bilateral lower extremities are not medically necessary at this time based on the peer reviewed literature. Standard of care would be evaluation in an outpatient clinic 3-6 weeks following endovenous ablation of left anterior accessory great saphenous vein and right great saphenous vein.