Is the requested Left Thigh Accessory Superficial Truncal Vein Varithena (polidocanol) USGS (Ultrasound-Guided Sclerotherapy) 36465 - NJX (Non-Compounded) NONCMPND (Non-Compounded) SCLRSNT (Sclerosant) 1 VEIN treatment medically necessary for a patient with varicose veins (I83.892) and is it considered experimental?

Medical Necessity Determination for Left Thigh Accessory Superficial Truncal Vein Varithena Treatment

Recommendation

This Varithena treatment for the left thigh accessory superficial truncal vein does NOT meet medical necessity criteria and should be DENIED due to inadequate documentation of medical-grade compression therapy trial. 1

Critical Missing Documentation

The patient failed to complete the required 3-month trial of medical-grade (20 mmHg or greater) gradient compression stockings as mandated by the Aetna policy criteria. 1 The documentation states the patient "tried compress over 2 yrs, not daily, seems to make edema worse she believes," which indicates:

• Non-compliance with daily compression therapy - the patient did not wear compression stockings consistently 1
• No documentation of medical-grade compression - there is no specification that 20 mmHg or greater gradient stockings were prescribed or used 1
• Subjective belief that compression worsens edema - this requires clinical evaluation and potential adjustment of compression therapy, not abandonment of conservative management 2

Why This Matters for Treatment Outcomes

The American Family Physician guidelines emphasize that compression therapy must be properly fitted and consistently worn before interventional therapy is considered. 2 The treatment algorithm specifically requires:

• Medical-grade compression (20-30 mmHg minimum) for symptomatic varicose veins 2, 3
• Daily compliance for at least 3 months to adequately assess symptom response 1, 3
• Proper fitting and patient education to address concerns about edema worsening 2

Clinical Context Supporting This Decision

While the patient meets several other criteria for treatment:

• Vein size criterion MET: Left accessory branch measures 4.5 mm (exceeds 2.5 mm threshold) 1
• Reflux criterion MET: Documented reflux of 1920 ms (exceeds 500 ms threshold) 1
• Symptomatic criterion MET: Severe pain and swelling interfering with daily activities 1
• No saphenofemoral junction reflux: GSV is competent, so junctional treatment is not required 1

However, the conservative management requirement remains unfulfilled, which is a mandatory prerequisite regardless of other criteria being met. 1, 3

Evidence-Based Treatment Algorithm

The Society for Vascular Surgery and American Venous Forum 2022 guidelines establish a clear hierarchy: 3, 4

1. Conservative management FIRST - including properly fitted medical-grade compression stockings worn daily for 3 months 3
2. Endovenous thermal ablation - for saphenous trunks ≥4.5 mm with documented reflux 4
3. Foam sclerotherapy (Varithena) - for tributary veins and accessory veins as adjunctive or secondary treatment 1, 4

For accessory superficial truncal veins specifically, foam sclerotherapy is appropriate ONLY after conservative management has been properly attempted and failed. 1, 4

Specific Requirements to Establish Medical Necessity

To approve this procedure, the following documentation must be obtained:

• Prescription for medical-grade compression stockings (20-30 mmHg gradient) with specific documentation of the compression class prescribed 2, 1
• Patient education documentation addressing the concern that compression worsens edema, including evaluation for proper sizing and fit 2
• Compliance monitoring for 3 months with documentation of daily wear and symptom response 1, 3
• Clinical reassessment after 3-month trial documenting persistent symptoms despite proper compression therapy 1, 3

Common Pitfalls to Avoid

The most common error in varicose vein treatment authorization is accepting patient self-report of compression therapy failure without objective documentation. 1 Key considerations:

• "Tried compression" is insufficient - must document medical-grade compression with specific mmHg rating 1
• Intermittent use does not constitute an adequate trial - daily compliance is required 2, 3
• Patient perception that compression worsens symptoms requires clinical investigation - may indicate improper sizing, incorrect compression class, or underlying lymphedema requiring different management 2

Strength of Evidence

This recommendation is based on:

• Level A evidence from American Family Physician guidelines (2019) requiring compression therapy trial before interventional treatment 2
• Explicit policy criteria from Aetna Clinical Policy Bulletin 0050 requiring medical-grade compression stockings as part of conservative management 1
• Society for Vascular Surgery/American Venous Forum 2022 guidelines establishing compression as first-line treatment 3, 4

Is This Treatment Experimental?

No, Varithena (polidocanol endovenous microfoam) is NOT experimental. 1, 5 It is an FDA-approved sclerosant with established efficacy:

• Foam sclerotherapy achieves 72-89% occlusion rates at 1 year for appropriately selected veins 1
• Polidocanol is a recognized sclerosing agent with no evidence of inferiority compared to other agents 2, 5
• The procedure is covered by CPT code 36465 and is considered standard of care for tributary and accessory veins when medical necessity criteria are met 1

The issue is not whether the treatment is experimental, but whether the patient has met the prerequisite conservative management requirements. 1, 3

Required Action Before Resubmission

The treating physician must document a proper 3-month trial of medical-grade (20-30 mmHg) compression stockings with daily compliance before this procedure can be approved. 1, 3 If the patient reports that compression worsens edema, clinical evaluation should include:

• Assessment for proper stocking fit and sizing 2
• Evaluation for concurrent lymphedema requiring different compression strategies 2
• Trial of different compression classes or types (e.g., graduated compression vs. uniform compression) 2
• Documentation of specific symptoms during compression use to differentiate true contraindication from improper application 2