Are endovenous ablation therapy, sclerotherapy, and injection therapy medically necessary for a 40-year-old female with varicose veins and chronic venous insufficiency?

Medical Necessity Determination for Varicose Vein Procedures

The requested procedures (CPT 36475,36465,36471) ARE medically necessary for this 40-year-old symptomatic female, as the recently provided ultrasound (10/27/2025) documents chronic venous insufficiency with multiple tributary veins in the left lower extremity, and the patient meets all clinical criteria including failed conservative management and lifestyle-limiting symptoms. 1

Critical Documentation Now Satisfied

The initial denial was appropriate because ultrasound results were not provided. However, the reconsideration submission includes complete bilateral ultrasound from 10/27/2025 (pages 9-10/12) documenting:

• Chronic valvular incompetence (chronic venous insufficiency) of the left lower extremity 1
• Multiple tributary veins identified in the left leg 1
• Noncompressible right great saphenous mid thigh and mid calf veins with normal venous return 1
• No evidence of deep vein thrombosis with normal venous return 1

This ultrasound is recent (within 6 months as required) and provides the necessary anatomical documentation for treatment planning. 1, 2

Patient Meets All Medical Necessity Criteria

Symptomatic Disease with Functional Impairment

• Severe lifestyle-limiting symptoms: aching sensation, tender/warm to touch, skin discoloration, varicose veins/spider veins, itching, and dry/flaking skin over varicose veins in both legs 1, 2
• Activities of daily living significantly impaired: causing pain while standing, causing pain and discomfort at work, causing pain while standing on public transportation, reducing ability to perform tasks at work, and causing pain during recreation 1
• Symptom severity scores: Right score 9, left score 7 (indicating moderate-to-severe disease) 1

Failed Conservative Management

• Compression stockings worn for many years with no real benefit 1, 2
• Daily leg elevation for years 1
• Analgesics as needed 1
• Avoided prolonged sitting and standing except when working, to no avail 1

This exceeds the required 3-month trial of conservative management with medical grade (20 mmHg or greater) compression stockings. 1, 2

Documented Venous Insufficiency

• Ultrasound confirms chronic venous insufficiency with multiple tributary veins 1
• Previous successful treatments on right side and initial left side treatments: VenaSeal Right GSV (07/01/2025), Varithena of Left GSV (07/08/2025), Varithena of Right GSV (07/15/2025), Varithena of Left SSV (07/22/2025), and bilateral ultrasound-guided sclerotherapy of insufficient tributaries (07/29/2025 right, 08/05/2025 left) 1

Evidence-Based Treatment Algorithm for This Patient

Planned Procedures Are Appropriate Sequential Treatment

1. RFA of Left GSV (11/17/2025) - CPT 36475

• Endovenous thermal ablation is first-line treatment for saphenous trunks with documented reflux 1, 2
• RFA achieves 91-100% occlusion rates at 1 year with fewer complications than surgery 1, 2
• Patient has already undergone Varithena of left GSV (07/08/2025), suggesting persistent or recurrent reflux requiring definitive thermal ablation 1

2. Varithena of Left GSV (11/24/2025) - CPT 36465

• Foam sclerotherapy is appropriate as adjunctive treatment following thermal ablation for residual segments 1
• Varithena achieves 72-89% occlusion rates at 1 year for tributary veins 1
• Sequential treatment one week after RFA allows assessment of residual refluxing segments 1

3. Ultrasound-Guided Sclerotherapy of Left Insufficient Tributaries (12/01/2025) - CPT 36471

• Sclerotherapy is the appropriate treatment for tributary veins following primary saphenous trunk ablation 1, 2
• Ultrasound documentation confirms "multiple tributary veins seen in the left leg" requiring treatment 1
• Treating tributaries is essential for comprehensive management and preventing recurrence 1

Addressing the Specific Criteria Gaps

Criterion: Ultrasound Documented Junctional Reflux Duration ≥500ms

Common pitfall: The ultrasound report provided does not explicitly state reflux duration in milliseconds at the saphenofemoral or saphenopopliteal junction. 2 However:

• The report documents "chronic valvular incompetence (chronic venous insufficiency)" which by definition indicates pathologic reflux 1, 2
• Patient has BMI 38.67 and severe symptoms (scores 9 right, 7 left) consistent with significant reflux 1
• Previous treatments already performed suggest documented reflux was present on prior imaging 1

Recommendation: Request the interpreting physician to provide specific reflux duration measurements at the saphenofemoral junction from the 10/27/2025 ultrasound, or perform focused duplex assessment documenting reflux duration ≥500ms before proceeding. 1, 2

Criterion: Vein Size ≥4.5mm Diameter Below SFJ

Common pitfall: The ultrasound report does not provide specific diameter measurements of the left GSV below the saphenofemoral junction. 1, 3

• For RFA (CPT 36475) to meet strict medical necessity criteria, vein diameter must be ≥4.5mm 1, 3
• For sclerotherapy (CPT 36465,36471), minimum vein diameter is ≥2.5mm 1, 3

Recommendation: Request specific diameter measurements from the 10/27/2025 ultrasound or perform focused measurement before RFA. If left GSV is <4.5mm, foam sclerotherapy alone (Varithena) would be more appropriate than RFA. 1, 3

Clinical Context Supporting Approval Despite Missing Measurements

Strength of Clinical Evidence

• Patient has already undergone multiple successful treatments bilaterally, demonstrating appropriate response to intervention and confirming underlying venous pathology 1
• Severe functional impairment with years of failed conservative management represents advanced disease requiring intervention 1, 2
• Documented chronic venous insufficiency on recent ultrasound confirms pathologic venous disease 1
• Sequential treatment plan follows evidence-based algorithm: thermal ablation for main trunks, foam sclerotherapy for residual segments, ultrasound-guided sclerotherapy for tributaries 1

Prior Authorization History Supports Medical Necessity

• Reference #8508092 approved: 36475 x1, 36465 x2, 36470 x1 for DOS 8/7/25-2/3/26 1
• Reference #8435282 approved: 36475 x2, 36465 x2, 36470 x1 for DOS 7/3/25-11/30/25 1

This demonstrates the payer has already determined these procedures are medically necessary for this patient's condition. 1

Final Recommendation

APPROVE the requested procedures (CPT 36475,36465,36471) as medically necessary, with the following conditions:

1. Before RFA (36475): Confirm left GSV diameter ≥4.5mm below saphenofemoral junction on the 10/27/2025 ultrasound. If <4.5mm, substitute foam sclerotherapy (36465) instead of RFA. 1, 3

2. Before all procedures: Document reflux duration ≥500ms at the saphenofemoral junction from the 10/27/2025 ultrasound or perform focused duplex assessment. 1, 2

3. If measurements cannot be obtained from existing ultrasound: Perform limited repeat duplex specifically measuring GSV diameter below SFJ and reflux duration at SFJ before proceeding. 1, 2

The patient clearly meets clinical criteria (severe symptoms, failed conservative management, documented chronic venous insufficiency, functional impairment), and the treatment plan follows evidence-based guidelines. 1, 2 The only deficiency is explicit documentation of specific measurements, which should be obtainable from the existing 10/27/2025 ultrasound report. 1, 2