Legwork Necessary When Considering Venous Disease Treatment
By Maureen Prowse
It is imperative that patients considering the management of venous disease determine whether the treatment is covered by their healthcare provider. Doing a little bit of research prior to treatment can help patients avoid getting stuck costly medical bills. Insureds should be aware that they have an Evidence of Coverage (EOC) document available to them through their medical insurance company. The EOC will differ depending on the form of coverage, be it an HMO, POS, PPO or through Medicare. Patients should obtain a copy of their EOC prior to seeking treatment by calling the customer service phone number on the insurance card.
Although Medicare and most health plans cover several treatments for venous disease, most insurance carriers do not cover the cosmetic procedures for spider veins. Getting medical approval is not quite so easy, according to Sanford J. Greenberg, M.D., medical director at Vein Doctor Medical Group in Palm Desert, Ca, who adds that there must be documentation of failed attempts at management of varicose veins. This may include 6-12 months’ use of compression stockings.
The EOC will state the definitions of what is considered to be “medically necessary” services as well as list the “exclusions.” Medically necessary services are supported by research reflecting the benefits of treatment over no treatment for that diagnosis. Such services almost always involve some attempts at conservative management of the symptoms associated with the diagnosis. Medically necessary services are also based on confirmation of the diagnosis.
Varicose veins are associated with symptoms of pain that might include throbbing, cramping, burning or even symptoms of restless legs. The health care provider will be looking for documentation of the symptoms that the patient has reported to the doctor. When varicose vein disease has affected a patient over a longer period of time, there will be chronic changes that are noted on the physical exam. Such changes may include discoloration of the skin, a dermatitis rash, ulcers and swelling. Severe complications from the disease will include episodes of deep vein thrombosis (DVT), from a blood clot within the dilated vessel. More severe complications might include an episode of severe bleeding from one of the dilated vessels or a pulmonary embolus from a DVT clot that travels to the lung. Confirmation of the diagnosis includes Doppler or duplex ultrasound scans that can even measure the size of the dilated vessels, which can establish the presence of incompetent valves that would normally prevent back flow. For some health plans, conservative attempts at management include the patient wearing compression stockings for 6-12 months.
The health plan will seek physician documentation which establishes the medical necessity for treatment. That documentation will need to include your symptoms and complications, the physical exam findings including the presence and location of the tortuous vessels, the confirmation of the diagnosis and the failure of any conservative attempts at management.
You can expect that your EOC will include an exclusion for cosmetic procedures. As spider veins have no complications and are associated only with mild or no symptoms, their treatment is considered to be cosmetic, and exclusion to coverage. Sclerotherapy for these spider veins will be considered a cosmetic treatment and not a covered service. However, sclerotherapy done at the time of a medically necessary procedure for varicose veins, such as stripping and ligation, may be considered a medically necessary procedure. Another insurance company considers sclerotherapy medically necessary when done on small to medium sized veins of less than 6 mm in diameter, but not when there is saphenofemoral or saphenopopliteal junction reflux. This makes if very difficult to “guess” what is covered and what is not covered.
With so many therapies for the treatment of varicose veins, it is difficult to know what is covered by your insurance carrier. It is also important that you allow yourself enough time to do the necessary research. This includes knowing the treatment that has been recommended for you, so that you may specifically ask about that treatment when you contact your insurance company to discuss your coverage. For instance, all of the insurance companies should have coverage for stripping and ligation of varicose veins, but not all of the insurance companies will cover all of the alternatives to this surgery.
The surgical procedure known as varicose vein ligation was at one time the most common procedure for treatment of varicose veins. The procedure, which required hospitalization and an extended recovery, has since been largely replaced with endovenous laser treatment, which is an office procedure. Aetna , BlueCross of California and CIGNA consider endoluminal radiofrequency ablation, as VNUS or RFA, and EVLT, endoluminal laser ablation, as acceptable alternative procedures to varicose vein stripping. Most insurance companies will approve endoluminal laser ablation (EVLT) as an authorizable alternative to varicose vein ligation. One of the insurance companies will not cover varicose vein procedures as medically necessary unless the measurement of the diameter of the veins is 3 mms or larger. Subfascial endoscopic perforator surgery (SEPS) is not a covered benefit for all of the insurance companies and not for all indications. SEPS for post-thrombotic syndrome is not considered medically necessary treatment.
Lastly, make sure that your doctor has documented your symptoms and the conservative attempts at management. In addition, be sure that you have had the tests needed to confirm the diagnosis. Review your EOC and discuss the specific treatment plan with your healthplan provider to confirm that you understand the coverage. Then, have your doctor submit the request for the procedure to the medical insurance plan prior to having the treatment. With the proper documentation of the vein disease with symptoms, signs, complications, and conservative treatments, the treatment plan should be approved. If you receive a denial for the requested treatment and believe otherwise, appeal the denial. By getting prior authorization you will avoid the shock of finding out after the fact that a treatment was not a covered expense.
Aetna, Clinical Policy Bulletin: Varicose Veins, Number:0050 www.aetna.com/cpb/medical/data/1_99/0050.html
BlueCross of California, Medical Policy, Treatment of Varicose Veins (lower Extremities) Policy #: SURG.00037 http://medpolicy.bluecrossca.com/main.html
CIGNA HealthCare Coverage Position, Varicose Vein Treatments, Coverage Position Number 0234, www.CIGNA.com/customer_care/healthcare_professional/coverage_positions/medical/mm_o234_coveragepositioncriteria_varicose_vein_treatments.pdf
Chronic Venous Insufficiency, Deron J. Tessier, MD Author, eMedicine from WebMD, http://www.emedicine.com/med/topic2760.htm
Merck Manuals Online Medical Library, Home Edition, Varicose Veins, www.merck.com/mmhe/sec03/ch036/ch036d.html#sec03-ch036-ch036d-1174
The Vein Doctor Medical Group, Dr. Sanford J. Greenberg, M. D. www.theveindoctor.com