202210-154312
2022
United Healthcare Plan of New York
HMO
Cardiac/ Circulatory Problems
Surgical Services
Medical necessity
Upheld
Case Summary
Diagnosis: Varicose Veins
Treatment: Endovascular Embolization (36465)
The insurer denied: Endovascular Embolization (36465)
The denial is upheld.
The patient is an elderly female. The patient presented with bilateral symptomatic varicose vein disease. She had failed a trial of compression stockings. Her symptoms were severe enough to interfere with normal function. Reflux testing showed bilateral great saphenous vein (GSV) and short saphenous vein (SSV) enlargement and incompetence. The right anterior accessory vein also had reflux.
The patient underwent right anterior accessory Varithena closure. Coverage of this procedure was denied by the health plan. The medical records do not show that any other vein intervention was done. The denial is being appealed.
The Endovascular Embolization (36465) was not medically necessary.
The standard of care for a patient such as this would indicate GSV (great saphenous vein) closure in the right leg because of symptoms that can be reasonably attributed to varicose vein disease and the symptoms adversely affected normal function; failed a trial of compression stockings; and duplex-proven reflux of the GSV (great saphenous vein).
However, rather than treat the GSV (great saphenous vein), the provider treated only the anterior accessory vein. It is not appropriate to treat the anterior accessory vein in an isolated fashion when the patient has severe GSV (great saphenous vein) reflux. Appropriate strategies when patients have reflux in both GSV (great saphenous vein) and anterior accessory vein are: (a) ablate the GSV (great saphenous vein) and later treat the accessory vein if the patient has residual symptoms; or (b) ablate both GSV (great saphenous vein) and accessory vein at the same setting.
Because the provider performed isolated anterior accessory closure, the procedure was not medically necessary.