Diagnosis: Cardiac Circulatory-varicose veins.
Treatment: Surgical Services.
The insurer denied ablation of right and left great saphenous veins. The denial is overturned.

The patient is a female who presented with bilateral lower extremity symptomatic varicose veins. Her main symptoms include cramping and swelling. Her symptoms are reported to interfere with her activities of daily living. The patient has attempted and failed conservative therapy with graded compression stockings. Her duplex scan demonstrates reflux in her bilateral great saphenous veins. Her provider is recommending endovenous ablation of her bilateral great saphenous veins for treatment of her condition.

The health plan's determination is overturned.

Bilateral great saphenous vein ablation is medically necessary for this patient based on the peer reviewed literature and the current standard of care in the vascular surgery community.

Endovenous ablation of the bilateral great saphenous veins is the current standard of care treatment for patients with symptomatic varicose veins and saphenous vein reflux. 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 her 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 75·0 (95 per cent confidence interval [c.i.] 68·0 to 82·0), 59·9 (52·1 to 67·7) and 81·3 (75·1 to 87·6) per cent respectively after 1 year.