Is endovenous ablation therapy (CPT code 36475) and sclerotherapy with Varithena (generic name: polidocanol) medically necessary for a patient with varicose veins of bilateral lower extremities, venous insufficiency, and persistent pain and swelling despite conservative management?

Medical Necessity Assessment for Endovenous Ablation and Sclerotherapy

Based on the clinical documentation provided, the requested procedures (CPT 36475 for endovenous ablation and CPT 36465 for sclerotherapy) are medically necessary for this 44-year-old male patient, but ONLY if the critical missing documentation regarding the 3-month conservative therapy trial can be confirmed.

Critical Documentation Gap

The primary concern is the absence of clear documentation regarding the duration and adequacy of conservative management 1. The progress note states "Given that the patient has attempted conservative therapy with little to no relief of symptoms," but this lacks the specific details required for medical necessity determination 1, 2.

Required documentation that must be verified:

• Documented 3-month trial of prescription-grade gradient compression stockings (minimum 20-30 mmHg) 1
• Specific dates of conservative therapy initiation and duration 1
• Documentation of compliance with compression therapy 1
• Evidence that symptoms persisted despite adequate conservative management 1, 2

Ultrasound Criteria Analysis - FULLY MET

The duplex ultrasound findings from 11/07/2025 exceed all required thresholds for medical necessity 1:

Left Lower Extremity (Primary Treatment Target):

• Saphenofemoral junction (SFJ) diameter: 11.4mm (requirement: ≥4.5mm) 1
• SFJ reflux time: 1900ms (requirement: ≥500ms) 1
• GSV proximal thigh diameter: 7.3mm (requirement: ≥4.5mm) 1
• GSV mid-thigh reflux: 5100ms (far exceeds threshold) 1
• SSV diameter: 4.0mm with reflux time 5900ms 1

Right Lower Extremity:

• SFJ diameter: 6.9mm with reflux time 2900ms 1
• All measurements exceed minimum thresholds 1

Symptom Criteria - MET

The patient presents with severe and persistent symptoms interfering with activities of daily living 1:

• Varicose veins of bilateral lower extremities with pain 1
• Localized edema 1
• Pain of left lower extremity 1
• Positive for venous reflux 1

These symptoms meet the criteria for "severe and persistent pain and swelling interfering with activities of daily living" as required by medical necessity guidelines 1, 2.

Evidence-Based Treatment Algorithm

Step 1: Endovenous Thermal Ablation (CPT 36475) - PRIMARY TREATMENT

The left GSV and SSV ablation is medically necessary and represents first-line treatment 1, 3:

• Endovenous thermal ablation is the first-line treatment for symptomatic varicose veins with documented valvular reflux, with technical success rates of 91-100% at 1 year 1
• The American College of Radiology designates endovenous thermal ablation as the appropriate first-line treatment for saphenofemoral junction reflux with vein diameter ≥4.5mm and reflux ≥500ms 1
• Treating the saphenofemoral junction is mandatory before tributary sclerotherapy to prevent recurrence, as untreated junctional reflux causes persistent downstream pressure leading to tributary vein recurrence rates of 20-28% at 5 years 1

Step 2: Foam Sclerotherapy with Varithena (CPT 36465) - ADJUNCTIVE TREATMENT

The planned Varithena treatment (5 total units) is medically necessary as adjunctive therapy 1, 3:

• Foam sclerotherapy is considered medically necessary adjunctive treatment for symptomatic tributary and accessory veins when performed concurrently with or following treatment of saphenofemoral junction reflux 1
• Varithena (polidocanol endovenous microfoam) is appropriate for veins ≥2.5mm in diameter with documented reflux 1, 2
• Foam sclerotherapy achieves occlusion rates of 72-89% at 1 year for tributary veins 1, 3
• The American College of Radiology recommends a combined approach with endovenous thermal ablation for main saphenous trunks and sclerotherapy for tributary veins 1

Treatment Sequence Rationale

The planned treatment sequence is evidence-based and appropriate 1, 3:

1. Ablation of left GSV/SSV first addresses the primary source of venous hypertension at the saphenofemoral and saphenopopliteal junctions 1
2. Concurrent or sequential Varithena for tributary veins provides comprehensive treatment of the entire refluxing venous system 1
3. Multiple studies demonstrate that chemical sclerotherapy alone has inferior long-term outcomes compared to thermal ablation, but as adjunctive therapy following junctional treatment, it represents appropriate care 1, 3

Common Pitfalls and How to Avoid Them

Critical pitfall to avoid: Performing sclerotherapy without treating saphenofemoral junction reflux leads to high recurrence rates 1. This patient's treatment plan appropriately addresses junctional reflux first 1.

Vein size considerations: Vessels <2.0mm treated with sclerotherapy have only 16% primary patency at 3 months compared to 76% for veins >2.0mm 1. The ultrasound should confirm that tributary veins targeted for Varithena meet the ≥2.5mm diameter threshold 1, 2.

Documentation requirements: The ultrasound was performed within the required 6-month window (11/07/2025) 1. However, specific measurements of tributary veins to be treated with Varithena must be documented 1, 2.

Strength of Evidence Assessment

• Level A evidence from American College of Radiology Appropriateness Criteria (2023) supports endovenous thermal ablation as first-line treatment 1
• Level A evidence from American Family Physician guidelines (2019) supports the treatment algorithm of thermal ablation followed by sclerotherapy 1, 3
• Moderate-quality evidence supports foam sclerotherapy as adjunctive treatment with 72-89% success rates 1, 3

Final Recommendation

APPROVE the requested procedures (CPT 36475 and 36465) contingent on verification of the 3-month conservative therapy trial 1, 2. The ultrasound findings, symptom severity, and treatment plan all meet medical necessity criteria 1. The only missing element is explicit documentation of the duration and adequacy of conservative management 1, 2.

If conservative therapy documentation cannot be verified: Request specific documentation including dates of compression stocking prescription, compliance assessment, and symptom persistence despite adequate trial 1, 2. Without this documentation, the procedures may not meet payer medical necessity criteria despite being clinically appropriate 1.