Are codes 36475, 36565, and 36471 medically necessary for a patient with varicose veins of bilateral lower extremities without recent Doppler or duplex ultrasound scanning and no documentation of prescription-grade support stockings for 3 months?

Medical Necessity Assessment: Procedures NOT Medically Necessary Without Required Documentation

The requested procedures (CPT codes 36475 x2, 36565 x2, and 36471 x2) are NOT medically necessary because critical documentation requirements are missing: no recent Doppler/duplex ultrasound report with specific measurements, and no documentation of a 3-month trial of prescription-grade compression stockings. 1, 2

Critical Missing Documentation

1. Absence of Required Doppler/Duplex Ultrasound Report

Duplex ultrasound performed within the past 6 months is mandatory before any interventional varicose vein therapy. 1

The following specific measurements MUST be documented for medical necessity:

• Reflux duration ≥500 milliseconds (0.5 seconds) at the saphenofemoral or saphenopopliteal junction 1, 2
• Vein diameter ≥4.5 mm measured below the saphenofemoral or saphenopopliteal junction for radiofrequency ablation (CPT 36475) 2, 3
• Vein diameter ≥2.5 mm for foam sclerotherapy/Varithena (CPT 36565,36471) 2, 4
• Exact anatomic location where measurements were obtained 2

The clinical documentation states "u/s: chronic venous insufficiency" but provides NO actual Doppler report with these required measurements. 1 The American College of Radiology explicitly states that duplex ultrasound should be the first assessment of the lower extremity venous system, and these specific parameters must be documented before treatment. 1

2. Inadequate Conservative Management Documentation

A documented 3-month trial of PRESCRIPTION-GRADE gradient compression stockings (20-30 mmHg minimum) is required before interventional treatment. 1, 2

The clinical documentation states: "Lisa has completed a 20-30lb compression stocking trial since 7/29/25" - this appears to be only approximately 4 months if the review date is late 2025, which may meet the timeframe requirement. 1

However, critical problems exist:

• The documentation states "20-30lb" which appears to be an error (should be "20-30 mmHg" for compression pressure) 1
• No documentation of prescription-grade stockings (versus over-the-counter) 2
• The American College of Radiology requires compression therapy with minimum pressure of 20-30 mmHg, with 30-40 mmHg advised for more severe disease 1

Why These Requirements Are Non-Negotiable

Ultrasound Measurements Determine Treatment Safety and Efficacy

Vein diameter directly predicts treatment outcomes and determines appropriate procedure selection. 2, 3

• Vessels <2.0 mm treated with sclerotherapy had only 16% primary patency at 3 months** compared with **76% for veins >2.0 mm 2
• Treating veins smaller than minimum thresholds results in poor outcomes with lower patency rates 2
• Radiofrequency ablation carries risks including deep venous thrombosis (0.3%), pulmonary embolism (0.1%), and nerve damage (approximately 7%) - proper patient selection based on ultrasound measurements is essential to justify these risks 2

Reflux Duration Distinguishes Pathologic from Physiologic Reflux

The 500-millisecond threshold is the established diagnostic criterion for venous insufficiency requiring intervention. 1, 2 Without documented reflux duration, there is no objective evidence that the patient has pathologic venous reflux warranting invasive procedures with associated risks.

Conservative Management Failure Must Be Documented

Compression therapy is the cornerstone of conservative management and must be attempted before invasive procedures. 1 The current published data show that while compression therapy alone may have inadequate evidence for C2-C4 disease, adherence should be encouraged and documented failure is required to justify the risks of invasive treatment. 1

Treatment Algorithm When Proper Documentation Exists

IF proper documentation were obtained, the treatment sequence would be: 2

1. First-line: Endovenous thermal ablation (RFA) for great saphenous vein or small saphenous vein with diameter ≥4.5 mm and reflux ≥500 ms at saphenofemoral or saphenopopliteal junction 2
2. Second-line/Adjunctive: Foam sclerotherapy (Varithena) for tributary veins ≥2.5 mm diameter AFTER or concurrent with treatment of main saphenous trunk 2, 4
3. Ultrasound-guided sclerotherapy for residual insufficient tributaries ≥2.5 mm 2

The American College of Radiology emphasizes that treating junctional reflux with thermal ablation is essential before tributary sclerotherapy to prevent recurrence. 2 Chemical sclerotherapy alone has inferior long-term outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation. 2

Required Actions Before Approval

To establish medical necessity, the following documentation must be provided: 1, 2

1. Recent duplex ultrasound report (within past 6 months) documenting:

   • Reflux duration in milliseconds at saphenofemoral/saphenopopliteal junctions (must be ≥500 ms)
   • Vein diameter in millimeters at specific anatomic locations (≥4.5 mm for RFA, ≥2.5 mm for sclerotherapy)
   • Specific laterality and vein segments to be treated
   • Assessment of deep venous system patency

2. Documentation of prescription-grade compression stockings trial:

   • Prescription for medical-grade gradient compression stockings (20-30 mmHg minimum)
   • Documentation of 3-month trial duration
   • Documentation of compliance and persistent symptoms despite proper use

Clinical Context Supporting Potential Medical Necessity

The patient's clinical presentation suggests legitimate venous disease: 2

• Symptoms include aching, swelling, skin discoloration, varicose veins, itching, and restless legs bilaterally
• Symptoms impair activities of daily living (pain while standing, pain at work, sleep loss, pain from swelling)
• CEAP classification appears to be C4 (skin changes) based on "skin discoloration" 2

However, without objective ultrasound measurements and proper conservative management documentation, the medical necessity cannot be established regardless of symptom severity. 1, 2

Common Pitfalls to Avoid

• Never approve varicose vein procedures without recent duplex ultrasound with specific measurements - physical examination and hand-held Doppler are insufficient 5, 6
• Ensure compression stocking trial is prescription-grade (not over-the-counter) with documented pressure specifications 1
• Verify that ultrasound measurements meet minimum thresholds - treating undersized veins leads to poor outcomes 2
• Confirm treatment sequence is appropriate - junctional reflux must be treated before or concurrent with tributary sclerotherapy 2