Are codes 36475, 37765, 37766, and 37799 medically necessary for a 56-year-old patient with varicose veins of bilateral lower extremities and pain, who has worn compression stockings for over 3 months and still experiences pain?

Medical Necessity Assessment for Varicose Vein Treatment Codes

Based on the Aetna criteria provided and the clinical documentation, these procedures are NOT medically necessary because the patient fails to meet two critical ultrasound measurement requirements, despite meeting the symptom and conservative treatment criteria.

Critical Deficiencies in Documentation

Missing Ultrasound Measurements

The case explicitly states "there is no Doppler report showing measurements and reflux times," which creates fundamental gaps in meeting medical necessity criteria 1, 2:

• Reflux duration requirement NOT MET: Aetna requires ultrasound-documented junctional reflux duration of ≥500 milliseconds at the saphenofemoral or saphenopopliteal junction. The clinical information mentions "reflux" but provides no quantified reflux times in milliseconds 1, 2.

• Vein diameter requirement NOT MET: Aetna requires vein size ≥4.5 mm measured by ultrasound below the saphenofemoral or saphenopopliteal junction. While the venous duplex shows measurements (left GSV with reflux from mid calf to SFJ, right varicosities measuring 3.2 mm and 3.0 mm), the right GSV "appears thrombosed" and "was not visualized in the proximal calf segment secondary to prior procedure," making diameter assessment incomplete 1, 2.

Specific Measurement Gaps

The provided venous duplex from the clinical record shows:

• Left side: GSV "appears patent with evidence of reflux from the mid calf to the SFJ" but no reflux duration in milliseconds is documented 1, 2
• Right side: GSV "appears thrombosed in the mid and distal thigh" with varicosities measuring only 3.2 mm and 3.0 mm, both below the 4.5 mm threshold 1, 2
• No specific reflux times are provided for either saphenofemoral junction 1, 2

Criteria Met vs. Not Met

Requirements Successfully Met

• Conservative treatment trial: Patient reports consistent use of compression stockings for over 3 months, meeting the 3-month trial requirement 1, 3
• Symptomatic presentation: Patient has severe and persistent pain and swelling interfering with activities of daily living (burning sensation, discomfort with prolonged standing, tenderness to palpation) 1, 3

Critical Requirements NOT Met

• Ultrasound-documented junctional reflux duration ≥500 ms: No reflux times in milliseconds are documented in the available duplex report 1, 2
• Vein diameter ≥4.5 mm: Right-sided varicosities measure only 3.0-3.2 mm; left GSV diameter below SFJ is not specified 1, 2

Required Actions for Medical Necessity

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

• Repeat or supplemental duplex ultrasound performed within the past 6 months documenting:

  • Exact reflux duration in milliseconds at the saphenofemoral junction bilaterally (must be ≥500 ms) 1, 2
  • Vein diameter measurements in millimeters below the saphenofemoral junction (must be ≥4.5 mm) 1, 2
  • Specific anatomic landmarks where measurements were obtained 2

• Documentation must explicitly state: "Reflux duration at the left saphenofemoral junction measures [X] milliseconds" and "Left GSV diameter below the SFJ measures [X] mm" 1, 2

Evidence-Based Rationale for These Requirements

Reflux duration >500 ms correlates with clinical manifestations of chronic venous disease and predicts benefit from intervention 2. Without quantified reflux times, it is impossible to distinguish pathological reflux requiring ablation from physiological reflux that does not warrant intervention 2.

Vein diameter directly predicts treatment outcomes and determines appropriate procedure selection 1, 2. Vessels <4.5 mm have lower success rates with thermal ablation, and vessels <2.5 mm have poor outcomes with sclerotherapy (only 16% primary patency at 3 months for veins <2.0 mm) 1.

Common Pitfall to Avoid

Clinical presentation alone cannot determine medical necessity 2. Multiple studies demonstrate that not all symptomatic varicose veins have saphenofemoral junction reflux requiring ablation 2. The presence of symptoms and failed conservative therapy, while necessary, are insufficient without objective ultrasound measurements meeting specific thresholds 1, 2.

Recommendation

Deny the procedures as currently documented and request comprehensive duplex ultrasound with specific measurements 1, 2. Once proper documentation confirms reflux duration ≥500 ms and vein diameter ≥4.5 mm, the procedures would become medically necessary given the patient's symptomatic presentation and failed conservative management 1, 2, 3.