Venous Insufficiency denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: This case involves a 29-year-old woman with a history and venous duplex consistent with venous insufficiency. The patient has requested authorization for endovenous laser therapy. However, the Health Plan denied her request indicating that endovenous ablation, via either a laser or radio-frequency energy source, is investigational and not a covered benefit. At issue is whether endovenous laser therapy is likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.Endovenous ablation is well studied and there are numerous publications including the recent article by Merchant et al. and a randomized, prospective trial conducted by Hinchliffe et al., which compared stripping to endovenous ablation for recurrent saphenous disease.

A 56-year-old female has requested approval for past treatment of varicose veins provided on three dates at issue on an emergent basis. Findings: The physician reviewer found that this patient had a long-standing history of venous insufficiency, although she had not followed through on definitive treatment. She reports that she was traveling throughout Europe and South America during the dates at issue and felt that her legs acutely worsened. She became concerned and sought treatment. Her physician in Ecuador recommended and performed bilateral greater and lessor saphenous vein ablations as well as phlebectomies. The patient states that she is now cured and she is seeking approval for these procedures on the basis that she required immediate medical attention.

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.

The patient is a 55-year-old male who presented with severe bilateral leg edema, felt to be a combination of lymphedema and venous insufficiency. A venous duplex study showed no evidence of deep venous obstruction. The patient had not used conservative measures such as leg elevation, compression stockings, or exercise. These measures were prescribed, as well as a pneumatic compression device. The patient did not return to the provider to assess the results of the conservative therapies or the compression device. The patient has requested reimbursement for the cost of the pneumatic compression device. The Health Plan denied his request based on a determination that the device was not medically necessary for the treatment of his venous stasis and lymphedema.Pneumatic compression devices or lymphedema pumps, are considered to be the `last resort` for managing lymphedema.

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 venous insufficiency, then check the rights and deadlines that apply to your plan.