202003-126735
2020
United Healthcare Ins. Co. of NY
Indemnity
Cardiac/ Circulatory Problems
Surgical Services
Medical necessity
Overturned
Case Summary
Diagnosis: Chronic Venous Insufficiency
Treatment: CPT code 36475 (Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated)
The insurer denied the CPT code 36475 (Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated).
The denial was reversed.
This is a female patient who underwent endovenous ablation therapy of an incompetent vein. It was reported in a letter of medical necessity detailing that the patient presented with complaints of left leg pain, aching and swelling. The patient had previously been treated with a left endovenous laser greater saphenous vein followed by sclerotherapy. The patient was doing well up until late 2019 when her symptoms returned. The patient had been utilizing compression stockings without improvement. The physician detailed that there was no deep venous thrombosis (DVT) upon ultrasound impression. There were posterior thigh tributaries at 6.5 mm with 4000 ms of reflux to the great saphenous vein as well as mid-thigh neo great saphenous vein 5.6 mm with 3000 ms of reflux. The small saphenous vein also had 3500 ms of reflux. The physician recommended endovenous radiofrequency ablation of the left small saphenous vein and ultrasound guided foam sclerotherapy. In mid 2019, the patient underwent an Endovenous Radiofrequency Ablation of the Left Small Saphenous Vein and Sclerotherapy of the Left Lower Extremity.
Based on the review of the medical record and the literature, the procedure of Left Small Saphenous Vein (Left SSV) and sclerotherapy of the left mid-thigh tributaries are medically indicated and should be approved. The rationale behind this is that with recurrent left leg edema and pain, despite previous venous interventions and utilizing conservative management with compression stockings. The patient's ultrasound revealed significant venous reflux of the left small saphenous vein and thigh tributaries. Thus, given the clinical findings and imaging, the above stated procedures were medically indicated.
Furthermore, much literature has been done in the past 10 years on combined endovenous thermal (EVLT or RT) ablation of varicose veins combined with foam sclerotherapy and studies reveal that the combined therapy is safe, and improve efficacy of treatments and prevent recurrence.
The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.
Based on the above, the medical necessity for CPT code 36475 (Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated) performed is substantiated. The insurer's denial should be reversed.