Diagnosis: Venous insufficiency.
Treatment: Procedure code 36475: Endovascular Ablation Therapy of Incompetent Extremity Veins.

The insurer denied coverage for procedure code 36475.

The denial is overturned.

This is a male patient with a medical history of venous insufficiency who was seen for a vascular follow-up. The patient continued to have symptoms to the right leg and complained of pain with heaviness with extreme discomfort. The patient has severe bilateral reflux, according to the physician, that has been treated conservatively with compression stockings. The patient has developed ulceration to the right ankle and continues to complain of swelling with pain. Upon physical examination, the patient had large varicose veins bilaterally with large tributaries. There was moderate to severe chronic venous changes noted. There was 5 millimeter (mm) ulceration with erythema. The patient was recommended to participate in ablation therapy. The patient's diagnostic study showed that the patient has evidence of reflux greater than 0.5 seconds bilaterally within the great saphenous vein (GSV) and common femoral vein (CFV). There is also venous insufficiency of greater than 0.5 seconds within the left sapheno-femoral junction (SFJ) and right short saphenous vein (SSV).

Based on the review of the medical record and literature, endovascular ablation therapy of incompetent extremity veins is considered medically necessary for this patient. This patient presented with a long-standing history of right leg edema, pain, heaviness, and bulging veins. Conservative management with compression stockings and elevation and rest had failed. Appropriate non-invasive workup with a venous reflux study documented >1 second of reflux throughout the right great saphenous vein (GSV) beginning at the proximal, mid, and below knee segments. In addition, there appears to be reflux in the left great saphenous vein (GSV) and the right short saphenous vein (SSV) as well. These clinical and imaging results clearly show that the patient's right GSV ablation is warranted and should be approved.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage of procedure code 36475: Endovascular Ablation Therapy of Incompetent Extremity Veins should be overturned. The medical necessity is substantiated.