Varicose Veins denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 35-year-old female with bilateral symptomatic varicose veins, worse on the right, with lipodermatosclerosis on her left calf. She has undergone phlebectomy and VNUS closure on the right leg in the past. The patient now has reflux on both legs, with 15 mm varices on the right from the mid-thigh down, and 6 mm varices on the left with reflux. The patient is very symptomatic with skin changes on the right leg, and has used compression stockings for years. The patient’s provider proposed endovenous laser therapy (EVLT) for treatment of the patient’s left leg and possible sclerotherapy on the right leg. The Health Plan has denied authorization and coverage for EVLT on the basis the requested procedure is considered investigational.Review of the relevant data demonstrates EVLT is not an investigational device.

Physician 1The patient is a 38-year-old woman with bilateral symptomatic venous disease due to greater saphenous vein incompetency. The patient has requested authorization for radiofrequency ablation, which has been denied by the Health Plan on the basis that it is considered investigational in nature.There is now sufficient peer-reviewed, randomized, controlled clinical trials with medium and long-term follow-up to support the use of radiofrequency ablation closure in the treatment of greater saphenous vein incompetence of symptomatic varicose veins. It is as effective as standard surgical therapy and is associated with significantly less rehabilitation and long-term morbidity. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.

Where the denial was upheld

Physician 1The patient is a 44-year-old male being evaluated for severe bilateral chronic venous insufficiency manifested by leg pain. The patient states that his activities of daily living are impacted. He complains of pain in both the thigh and calf areas. The patient has bilateral venous stasis leg ulcers with hemosiderin deposition of both medial ankles. He underwent left leg stripping and ligation of his greater saphenous vein (GSV) in 1994 with painful recurrence since 1997. He then underwent injection sclerotherapy and repeat local venous stripping. An ultrasound showed reflux on his right leg saphenofemoral junction and a large bulb of about 15.3mm. Left saphenofemoral junction also has large bilateral venous varicosities with reflux in the medial thighs and calves.

Physician 1The patient is a 47-year-old woman with a long history of varicose veins. The patient’s provider has recommended endovenous radiofrequency ablation of the patient’s left leg varices. The Health Plan has denied authorization and coverage for radiofrequency ablation (RFA) on the basis that it is considered investigational.The patient has symptomatic varicose veins. Based upon the patient’s physical exam it appears the patient has greater saphenous vein (GSV) incompetence with normal deep venous system. This clinical situation is best treated by elimination of the GSV and varicose veins. There is a great deal of peer-reviewed literature including randomized, controlled trials that support the long and short-term efficacy of RFA as opposed to stripping for patients such as this patient.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving varicose veins, then check the rights and deadlines that apply to your plan.