Diagnosis: Varicose vein.
Treatment: Outpatient procedure (37765 x 1 & 37766 x 1).

The insurer denied coverage for outpatient procedure (37765 x 1 & 37766 x 1).

The denial is overturned.

According to medical records, the patient is an adult with symptomatic varicose veins in the popliteal space behind the right knee. An ultrasound examination has demonstrated the absence of venous reflux. The treating physician requests authorization for phlebectomy of the painful varicose veins.

(Masuda et. al) state that "Treatment of nontruncal varicose veins with or without telangiectasia by sclerotherapy, ambulatory phlebectomy, or powered phlebectomy in a symptomatic patient with varicose veins, edema due to venous disease, skin or subcutaneous changes, healed or active ulcers " is considered appropriate.

"Physical methods for treating chronic venous disease (CVD) are studied increasingly as an adjunct or alternative to interventional treatment. Physical exercise, targeting lower limb muscle strength and ankle mobility, and physiotherapy may improve general mobility, promote weight loss, strengthen the calf muscle pump, and increase the range of ankle movements, all these facilitating venous return. Nevertheless larger studies are still needed. Subsequently this may reduce leg edema and prevent or ameliorate skin changes caused by CVD. Despite the paucity of studies specifically on chronic venous insufficiency (CVI), the indirect evidence for the benefit of exercise on venous function is considerable and thus it should be promoted. Leg elevation and the use of insoles to improve the foot muscle pump may be beneficial but most studies are small. Other methods with less evidence for treatment of CVD, but with improvement of health related quality of life (QoL), include massage, balneotherapy, and cooling therapy." (De Maeseneer, M. G. et al. 2022).

"Lower extremity venous insufficiency is a heterogeneous medical condition whose spectrum ranges from cosmetic abnormalities including spider telangiectasias to varicose veins with or without associated signs and symptoms including severe edema, skin ulceration, and subsequent major disability. Venous hypertension caused by incompetent valves in the superficial veins is by far the most common cause of this condition. This document will review the appropriate means by which ambulatory phlebectomy (AP) is to be used to maximize the benefit for patients who undergo the procedure." (Kundu, S. et al. 2019).

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for outpatient procedure (37765 x 1 & 37766 x 1) is substantiated.