Diagnosis: Varicose veins

Treatment: Procedure code 36475, endoluminal ablation of varicose veins

The insurer denied coverage for procedure code 36475, endoluminal ablation of varicose veins.

The denial is overturned.

This patient was seen for a consultation with complaints of varicose veins. The documentation indicated exacerbating factors to consist of the affected extremity being in a dependent position. Relieving factors consist of elevation and support hose. The patient did indicate she has been participating in conservative therapy for greater than 6 months. Physical examination revealed evidence of CEAP [C = clinical condition, E = etiology, A = anatomic location, P = pathophysiology] 2-varicose veins. The physician indicated a reflux study revealed reflux greater than 500 to the greater saphenous vein. It was recommended she undergo additional definitive treatment. The request has been received for CPT (current procedural terminology) code 36475. Additional documentation from the physician indicated she has had associated symptoms of ulcers, tenderness and edema and has had treatment with a partial great saphenous vein ablation a few years prior. However, she has developed reflux to the remnant great saphenous vein that require surgical intervention. The physician again indicated due to the above it was recommended she undergo right remnant great saphenous ablation and stab phlebectomies.
The procedure of right lower extremity GSV (great saphenous vein) RF (radio frequency) ablation, 36475, is not a cosmetic procedure, but a medically necessary procedure for symptomatic right lower extremity superficial venous insufficiency refractory to conservative measures.

This patient had a past history of superficial venous insufficiency and status post right GSV RF ablation in the past, who presents to the vascular clinic with recurrent symptoms of right leg edema, pain, fullness and tightness. She had tried elevation, compression stockings >6 months and avoiding prolonged standing.

She had a venous reflux study performed, which revealed the upper GSV was ablated, but that the mid-thigh and distal GSV had reflux >0.5 sec (meets criteria).

Thus, given that the patient had recurrent symptoms, had failed conservative management, and had proven superficial venous reflux in the remnant right mid to distal GSV, treatment with RF ablation is indicated. Repeat procedures are efficacious and are recognized as such in the literature and the vascular community as standard of care.

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

The insurer's denial of coverage for procedure code 36475, endoluminal ablation of varicose veins is overturned. Medical necessity is substantiated.