Is stab phlebectomy (37765) of the right branch of the saphenous vein medically necessary for a 38-year-old female with chronic venous insufficiency (Peripheral) (I87.2) and symptoms of leg heaviness, swelling, and cramping?

Medical Necessity Assessment for Stab Phlebectomy of Right Lesser Saphenous Vein Branch

Stab phlebectomy (37765) of the right branch of the lesser saphenous vein is medically necessary for this 38-year-old female with chronic venous insufficiency and symptomatic varicose veins, provided the procedure is performed concurrently with or after treatment of the underlying saphenopopliteal junction reflux. 1

Critical Criteria Analysis

Criteria Met Based on Documentation

Vein Size Requirements:

• The ultrasound documents a proximal calf branch measuring 5 mm in diameter, which exceeds the minimum threshold of 3 mm for stab phlebectomy 1
• The proximal medial branch measures 4 mm, also meeting size criteria 1
• Vessels must be measured while the patient is standing to ensure accurate assessment 1

Documented Reflux:

• The proximal calf branch demonstrates 8.1 seconds of reflux, far exceeding the 500 millisecond threshold 1, 2
• The proximal medial branch shows 9.1 seconds of reflux 1, 2
• These prolonged reflux times indicate severe venous insufficiency requiring intervention 2, 3

Symptomatic Functional Impairment:

• The patient reports leg heaviness, swelling, and cramping that interfere with daily activities 1, 2
• These symptoms represent lifestyle-limiting manifestations of venous insufficiency 2

Conservative Management:

• Compression stockings have been utilized, meeting the requirement for conservative therapy trial 1, 2

Exclusion Criteria Satisfied:

• No deep venous thrombosis documented on ultrasound 1
• No clinically significant arterial disease mentioned 1
• No evidence of lymphedema, severe peripheral edema, or overlying infection 1

Critical Gap in Medical Necessity: Treatment Sequencing

The primary concern is whether the saphenopopliteal junction (SPJ) reflux has been adequately addressed. 1, 2

Treatment Algorithm Requirements

First-Line Treatment Must Address Junctional Reflux:

• The ultrasound documents "positive reflux in SSV SPJ" (small saphenous vein at saphenopopliteal junction) 2, 3
• Stab phlebectomy is only medically necessary when performed concurrently with or after treatment of the saphenopopliteal junction reflux 1, 2
• Treating tributary branches without addressing junctional reflux leads to recurrence rates of 20-28% at 5 years 2

Previous Ablation History:

• The patient underwent laser ablation of the right lesser saphenous vein in May 2019 2, 3
• The current ultrasound from September 2025 shows the vein "looks slightly worse than before but minimally worse" 2
• This suggests either incomplete initial treatment or recurrent reflux at the SPJ 2, 3

Documentation Needed for Full Approval

To establish complete medical necessity, the following must be clarified:

1. SPJ Reflux Status: The ultrasound notes "positive reflux in SSV SPJ" but does not specify the exact reflux duration at the junction itself 2, 3

   • Medical necessity requires documented SPJ reflux duration ≥500 milliseconds 1, 2
   • The exact diameter of the SSV at the SPJ should be documented 2, 3

2. Status of Previous Ablation:

   • Is the previously ablated SSV segment occluded or patent? 3
   • If patent with reflux, the SPJ requires re-treatment before or concurrent with phlebectomy 1, 2
   • The note states "SSV proximal/mid through mid-segment not visualized," which is concerning 2

3. Treatment Plan Clarification:

   • The physician plans "ambulatory phlebectomy of the branch of the lesser saphenous vein" 2
   • This does not explicitly state treatment of the SPJ reflux 1, 2
   • Without concurrent SPJ treatment, the phlebectomy alone does not meet medical necessity criteria 1, 2

Evidence-Based Recommendation

The stab phlebectomy meets most medical necessity criteria, but approval should be contingent on one of the following:

Option 1: Concurrent SPJ Treatment (Preferred)

• Perform endovenous thermal ablation (radiofrequency or laser) of the SSV from the SPJ concurrently with the planned phlebectomy 2, 3
• This addresses the source of reflux and treats the symptomatic tributary branches in a single session 2
• Success rates for combined treatment approach: 91-100% occlusion at 1 year 3

Option 2: Staged Approach

• If the previous ablation successfully occluded the main SSV trunk and the current reflux is isolated to the branch vessels, phlebectomy alone may be appropriate 4
• However, this requires explicit documentation that the SPJ and main SSV trunk are occluded without reflux 2, 3

Option 3: Alternative to Phlebectomy

• Foam sclerotherapy (ultrasound-guided) could treat these branch vessels with 72-89% occlusion rates at 1 year 2
• This may be considered if surgical phlebectomy is declined or contraindicated 2

Clinical Considerations and Pitfalls

Common Pitfall: Treating Tributaries Without Addressing Source

• The most frequent cause of varicose vein recurrence is failure to treat junctional reflux 2
• Chemical sclerotherapy or phlebectomy alone has inferior long-term outcomes compared to thermal ablation of the main trunk 2

Anatomic Consideration:

• The lesser saphenous vein anatomy is highly variable, and the SPJ location can vary 5
• The sural nerve runs alongside the SSV, creating risk of nerve injury during procedures 5
• Stab phlebectomy technique minimizes this risk compared to traditional stripping 6, 5

Expected Outcomes:

• If SPJ reflux is adequately treated, phlebectomy of symptomatic branches provides excellent symptom relief 4, 6
• Approximately 65% of patients require no further treatment after addressing the main trunk, while 25-35% benefit from subsequent tributary treatment 4

Potential Complications:

• Phlebitis, hematoma, and residual pigmentation are common minor complications 1
• Deep vein thrombosis occurs in approximately 0.3% of cases 3
• Temporary sensory nerve injury may occur but is usually self-limited 6, 5

Final Determination

Approve stab phlebectomy with the requirement that the treatment plan includes concurrent or prior treatment of the saphenopopliteal junction reflux documented on the September 2025 ultrasound. 1, 2 If the physician's plan addresses only the tributary branches without treating the SPJ reflux, request clarification or modification of the treatment plan to include SPJ ablation. 1, 2, 3