Are procedures 37765 and 37766 (Stab Phlebectomy) medically necessary for a patient with varicosity on the back of their left leg, who has failed conservative treatment and has symptoms of pain, throbbing, and achiness?

Stab Phlebectomy is NOT Medically Necessary for This Patient

This patient does not meet the critical vein diameter threshold required for stab phlebectomy (CPT 37765,37766), as the tributary vein measures only 2.1 mm at its origin, which falls below the 2.5 mm minimum diameter requirement for medical necessity. 1, 2

Critical Missing Criteria Analysis

Vein Diameter Requirement NOT MET

• The tributary vein measures 2.1 mm in diameter at its origin, which is below the 2.5 mm minimum threshold required for ambulatory phlebectomy 1, 2
• Evidence demonstrates that vessels less than 2.0 mm treated with sclerotherapy had only 16% primary patency at 3 months compared with 76% for veins greater than 2.0 mm, indicating poor outcomes for smaller veins 1
• The American College of Radiology explicitly recommends stab phlebectomy only for tributary varicosities that are 3 mm or more in diameter when standing 2

GSV Diameter Requirement NOT MET

• The GSV measures 3.9 mm with reflux >2 seconds, which is below the 4.5 mm minimum diameter threshold required for saphenous vein treatment 1, 3
• Medical necessity criteria require vein size of 4.5 mm or greater in diameter measured by ultrasound below the saphenofemoral or saphenopopliteal junction 1
• The patient's GSV diameter of 3.9 mm does not meet this critical threshold for primary saphenous vein ablation 3

Treatment Algorithm Based on Current Evidence

Step 1: Address the Underlying Saphenous Vein Reflux FIRST

• The patient has documented GSV reflux >2 seconds (exceeds the 500 millisecond threshold), but the vein diameter of 3.9 mm is insufficient for standard endovenous thermal ablation 1, 3
• The American College of Radiology emphasizes that saphenous vein ablation should precede or be performed concurrently with stab phlebectomy for optimal outcomes 2
• Treating tributary veins without addressing underlying saphenous reflux results in high recurrence rates and poor long-term outcomes 1

Step 2: Consider Alternative Treatment for Small Diameter Veins

• For the 2.1 mm tributary vein, foam sclerotherapy (not stab phlebectomy) is the appropriate treatment modality 1, 4
• Ultrasound-guided polidocanol/CO2 foam sclerotherapy is specifically indicated for small tributary varicosities and has demonstrated 72-89% occlusion rates at 1 year 1, 4
• A recent protocol study showed that immediate ultrasound-guided foam sclerotherapy of bleeding varicosities, followed by endovenous ablation of incompetent axial veins within 8 weeks, provided 93% freedom from recurrent hemorrhage at 2.2 years follow-up 4

Clinical Context Supporting This Decision

The "Balloon-Like" Surface Varicosity

• While the documentation describes a "balloon-like area on the skin surface" that is "slightly ulcerated with predisposition for bleeding," this represents a surface manifestation rather than a deep tributary requiring phlebectomy 4
• This clinical presentation is precisely the indication for immediate foam sclerotherapy rather than surgical phlebectomy 4
• The 2025 study demonstrated that 95% of bleeding varicosities had an ultrasound-identified tributary underlying the bleeding point, and immediate foam sclerotherapy prevented recurrent bleeding in 93% of cases 4

Post-RFA Recurrence Pattern

• The patient is status-post left GSV radiofrequency ablation that has "reopened," indicating treatment failure of the primary saphenous trunk 1
• Performing stab phlebectomy on a 2.1 mm tributary without addressing the recurrent GSV reflux (3.9 mm with >2 second reflux) will likely result in continued symptoms and recurrence 1, 2

Evidence-Based Recommendation

Appropriate Treatment Sequence

1. Immediate ultrasound-guided foam sclerotherapy of the symptomatic tributary and surface varicosity to address the bleeding risk and acute symptoms 4
2. Re-evaluation of the GSV reflux (3.9 mm diameter, >2 second reflux) to determine if repeat ablation or alternative treatment is warranted, as the vein is below the standard 4.5 mm threshold but demonstrates significant reflux 1, 3
3. Consider foam sclerotherapy for the GSV if diameter remains below 4.5 mm, as this represents an appropriate alternative for smaller diameter veins with documented reflux 1

Why Stab Phlebectomy is NOT Appropriate

• The 2.1 mm tributary diameter is too small for effective phlebectomy and carries high risk of poor outcomes 1, 2
• Performing phlebectomy without addressing the underlying GSV reflux violates evidence-based treatment algorithms and increases recurrence risk 1, 2
• The clinical presentation of a bleeding varicosity is specifically an indication for foam sclerotherapy, not surgical phlebectomy 4

Strength of Evidence Assessment

This recommendation is based on:

• Level A evidence from American College of Radiology Appropriateness Criteria (2023) requiring minimum vein diameters of 2.5 mm for phlebectomy and 4.5 mm for saphenous ablation 1, 2
• High-quality prospective registry data (2025) demonstrating 93% success with foam sclerotherapy for bleeding varicosities followed by axial vein ablation 4
• Moderate-quality evidence showing 16% patency for veins <2.0 mm versus 76% for veins >2.0 mm, supporting size-based treatment selection 1

The requested stab phlebectomy procedures (37765,37766) are NOT medically necessary because the patient fails to meet the minimum vein diameter criteria (2.1 mm vs. required 2.5 mm minimum) and the treatment sequence violates evidence-based guidelines by attempting tributary treatment before addressing underlying saphenous reflux. 1, 2, 4