Are procedures 37765 and 37766 (Stab Phlebectomy for Varicose Veins) medically necessary for a patient with varicosity on the back of their left leg, who has failed conservative therapy, including compressive stockings (20-30 mmHg) and medications like Advil (ibuprofen) and Motrin (ibuprofen), and has a history of saphenous vein radiofrequency ablation (RFA)?

Medical Necessity Assessment for Stab Phlebectomy (CPT 37765,37766)

Based on the clinical documentation provided, the requested stab phlebectomy procedures are NOT medically necessary because the patient fails to meet the critical vein diameter criterion of ≥2.5mm required for ambulatory phlebectomy. 1

Critical Criterion Not Met: Vein Diameter

The patient's tributary vein measures only 2.1mm at its origin, which falls below the 2.5mm minimum diameter threshold required for medical necessity of phlebectomy procedures. 1 This size criterion is evidence-based, as vessels less than 2.0mm treated with any intervention demonstrate only 16% primary patency at 3 months compared with 76% for veins greater than 2.0mm. 1

• The ultrasound documents a tributary with reflux >2 seconds measuring 2.1mm in the left calf, which does not meet the ≥2.5mm diameter requirement 1
• While the vein "blows up to a larger balloon-like area on the skin surface," medical necessity is determined by the measured vein diameter at its origin (2.1mm), not the superficial varicosity size 1

Criteria Successfully Met

The patient does meet several other important criteria:

• Documented reflux >500ms: The tributary shows reflux >2 seconds (2000ms), exceeding the 500ms threshold 1, 2
• Failed conservative therapy: Completed 3-month trial of 20-30mmHg compression stockings, NSAIDs, and leg elevation 1, 2
• Symptomatic disease: Pain, throbbing, and achiness limiting daily activities and quality of life 1, 2
• Prior junctional treatment: History of left GSV radiofrequency ablation (though reopened), addressing the saphenofemoral junction reflux requirement 1

Alternative Treatment Recommendation

For this 2.1mm tributary vein with documented reflux and symptoms, foam sclerotherapy (Varithena/polidocanol) represents the appropriate evidence-based treatment rather than phlebectomy. 1

• Sclerotherapy is specifically indicated for veins 2.5-4.5mm in diameter, and can be considered for smaller vessels when symptomatic 1
• Foam sclerotherapy achieves 72-89% occlusion rates at 1 year for tributary veins 1
• The American College of Radiology recognizes sclerotherapy as appropriate treatment for tributary veins following primary saphenous trunk ablation 1

Clinical Context and Nuances

The presence of a "slightly ulcerated" area with predisposition for bleeding represents a concerning finding that warrants intervention, but does not override the size-based medical necessity criteria for phlebectomy. 1, 2

• Patients with venous ulceration may benefit from expedited treatment without requiring prolonged conservative therapy trials 2
• However, the appropriate intervention must still match the vein anatomy—in this case, sclerotherapy rather than phlebectomy 1

The patient's recurrent GSV (reopened after prior RFA) requires reassessment and likely retreatment before addressing tributary veins. 1

• The ultrasound shows GSV measuring 3.9mm with reflux >2 seconds, which meets criteria for repeat endovenous thermal ablation (diameter ≥4.5mm threshold not met, but 3.9mm with documented junctional reflux may still warrant treatment) 1, 2
• Treating junctional reflux is essential before tributary sclerotherapy to prevent recurrence, as untreated junctional reflux causes persistent downstream pressure leading to tributary vein recurrence 1

Common Pitfall to Avoid

Do not confuse the superficial varicosity size with the underlying vein diameter measured by ultrasound. The "balloon-like area on the skin surface" may appear large clinically, but medical necessity is determined by the ultrasound-measured vein diameter at its origin (2.1mm in this case), which predicts treatment outcomes and determines appropriate procedure selection. 1

Recommended Treatment Algorithm

1. Repeat ultrasound evaluation to confirm current GSV status and measure exact tributary vein diameters at multiple points 1
2. If GSV remains incompetent: Repeat radiofrequency ablation of the left GSV to address saphenofemoral junction reflux 1, 2
3. For the 2.1mm tributary: Ultrasound-guided foam sclerotherapy rather than phlebectomy 1
4. Address the ulcerated area: May require wound care in addition to treating underlying venous reflux 2