Vein Stripping denials in California external review

What the reviewers wrote

Where the denial was overturned

A 48-year-old female enrollee requested endovenous laser ablation (CPT code 36478 x 2 for both greater saphenous veins) for medical treatment of the enrollee’s varicose veins. Findings: Two physician reviewers found that review of the submitted documentation and relevant literature supports the requested services in this clinical setting. The patient has significant long-standing symptoms and a CEAP classification of level 3 venous disease of the left leg. Her symptoms of edema, varicosities, and dilatation of the greater saphenous vein suggest long-standing venous reflux in this left leg. She also has significant reflux and dilatation of the bilateral lesser saphenous veins. Given these findings the requested services are clinically indicated.

The patient is a 41-year-old female with a prior history of varicose veins with removal, but no history of greater saphenous vein removal. The patient indicates she is now experiencing severe pain due to her varicose veins, which have been refractory to conservative treatment (i.e., stockings). The results of an ultrasound exam show bilateral greater saphenous vein reflux. The patient’s provider has recommended the patient undergo repeat vein stripping.Given these facts, radiofrequency ablation closure of greater saphenous veins with removal of painful varicose veins is clinically indicated and medically necessary. The patient has greater saphenous vein reflux, which is an anatomic deficiency. The standard of care for this symptomatic patient is vein stripping.

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.

The patient is a 37-year-old female with leg pain. She was referred to a vascular surgeon, who performed photoplethysmography and concluded that she needed high ligation and stripping of the left saphenous vein. There is no mention that compression stockings were used or that other studies, like venous duplex, were performed. The record does not provide much detail as to clinical symptoms or physical exam findings. The patient has requested authorization for the recommended procedure. The Health Plan has denied this request based upon a determination that saphenous vein stripping is not medically necessary.Photoplethysmography is a rudimentary method, which uses a transducer that emits infrared light into the dermis. The back-scattered light is measured by a photodetector and displayed as a line tracing.

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