Stab Phlebectomy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for a procedure to surgically remove the varicose veins. The enrollee has bilateral lower extremity varicose veins. The record indicates she is experiencing a sense of swelling, heaviness, and pain in her legs when she tries to work out. Her symptoms are advancing despite wearing compression hose. The pain is interfering with her ability to work and becomes so intense as to make her physically ill. Findings: . Her physician documented a cluster of moderate-sized varicose veins on the medial aspect of her right leg, varicosities in the proximal medial thigh with vulvar varicosities, and varicosities measuring over 6 mm in size on the medial aspect of the left leg and thigh. Ankle swelling is minimal. She has no reflux in the greater saphenous vein.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a stab phlebectomy procedure. Varicose veins are usually caused by superficial venous incompetence, which may involve the saphenous veins, their tributaries, or both. Studies have shown that treatment of patients presenting with great saphenous vein (GSV) reflux and a large varicose GSV tributary by means of isolated ambulatory phlebectomy resulted in the abolishment of reflux. There is credibility to isolated phlebectomy as a viable treatment option for chronic venous insufficiency regardless of the presence of reflux in the truncal saphenous system.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency, first vein treated left greater saphenous vein and, stab phlebectomy of varicose veins, one extremity, more than 20 incisions. Findings: The physician reviewer found that the recommend compression therapy for patients with symptomatic varicose veins, and endovenous thermal ablation for treatment of an incompetent great saphenous vein. In this case, the submitted records noted paresthesias affecting the left foot and toes, possibly neuropathic in nature. The documentation did not describe symptoms within the distribution of the veins to be treated, multiple episodes of superficial thrombophlebitis, or mention phlebitis.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for varicose vein treatment (duplex scan of extremity vein and stab phlebectomy). The submitted documentation does not support the medical necessity of the requested vein surgery. The patient reported that she is experiencing severe pain and is unable to walk. The record indicates that the patient has a 2 mm varicose vein at the knee. However, the records lack documentation of a physical examination. It is not possible to attribute the patient’s symptoms to the 2 mm varicose vein without a physical examination, including an evaluation of lower extremity arterial perfusion.

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