Sclerotherapy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sclerotherapy on varicose veins of the right leg. The peer-reviewed medical literature supports sclerotherapy as an established treatment modality for patients with symptomatic varicose veins. The evolution of cyanoacrylate ablation or foam sclerotherapy of varicosities has become the standard of care treatment for patients with symptomatic varicosities. Sclerotherapy has been demonstrated to be less invasive than surgical methods and does not require anesthesia. The current clinical trials have reported both short- and long-term equivalency in closure with sclerotherapy when compared to more invasive procedures such as radiofrequency ablation. The benefits associated with sclerotherapy include a minimally invasive method that can be accomplished in an outpatient setting without incision.

A 51-year-old female has requested endovenous chemical ablation, left leg, using CPT code 37799 x 2 units (two dates of service), and endovenous chemical ablation, right leg, using CPT code 37799 x 1 (one date of service), in addition to sclerotherapy, right leg, using CPT code 36471 for treatment of her varicose veins. Findings: Two physician reviewers found that the patient has a long standing history of bilateral lower extremity varicose veins who presents complaining of bilateral leg pain and swelling severe enough to require over the counter analgesic medication. She is status post left short saphenous ligation and stripping about 15 years ago. There is documentation of palpable pedal pulses bilaterally. On duplex there is no evidence of deep vein thrombosis (DVT) or superficial thrombosis.

Where the denial was upheld

Physician #1: The patient is a 52-year-old female who has had telangiectasias and recurrent varices, which initially started when she was 24, and was treated with sclerotherapy. She has now experienced a recurrence with mild swelling and heaviness symptoms. The patient’s duplex exam did not show any greater saphenous vein (GSV) reflux in either leg, only a localized area of reflux on the left leg, which it seems is not intended to be addressed with the proposed treatment. At issue is whether sclerotherapy with topical laser ablation as suggested by the patient’s physician is likely to be more beneficial than standard therapy.Telangiectasias and small reticular veins are generally considered to be cosmetic, though they sometimes may cause symptoms as has occurred in this case.

Physician 1: The patient is a 62-year-old male with post-phlebitic syndrome and a history of deep vein thromboses (DVT). He has associated lymphedema and varicose veins secondary to his DVT. The patient has bilateral deep venous incompetence with residual thrombus in his right leg. His provider has requested authorization for endovenous laser ablation and six sessions of ultrasound guided sclerotherapy for both legs. The Health Plan denied the request citing the experimental/investigational nature of the therapy.The patient has symptomatic post-thrombotic syndrome. Interventions on the right greater saphenous vein and multiple varicosities could potentially worsen his condition. Intervention on his left leg may assist his condition. The patient is at high risk for recurrent DVT on the right, irrespective of the modality used.

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