This is a follow up to my previous blog post regarding venous ablation procedures. I recently had an eye-opening conversation with a vascular surgeon, Jane Lingelbach, MD, with whom I work closely at Healogics Wound Care Center. She recently expressed why there is a delay of treatment from the time of a requested consult to the time of a venous ablation procedure performed due to an ulceration in the presence of venous disease if indicated.

Dr. Lingelbach says there is often a a lag time between her recommendation and treatment, calling it “all insurance driven.” The mainstay requirement for most insurance is that the patient must have attempted three months of conventional compression therapy prior to a venous procedure. This could have started prior to the initial patient presentation. She said in extreme cases, insurance companies may ask for proof of purchase if patients were using compression stockings. She recommends her patients save their receipts. Also, according to Dr. Lingelbach, it is important to document when the patient first started any compression therapy.

For example, if patients state that their primary care physician recommended compression stockings and they have been wearing them for one month, one needs to document this. Therefore, we have to try two more months of conventional treatment prior to the patient having a venous ablation procedure.

According to , the HMO and PPO insurance companies use varying criteria in order to determine if they may consider vein treatment to be “medically necessary.” These criteria may include one or more of the following factors.

• Lifestyle disruption. The daily activities of the patient must be disrupted significantly.
• Pain. The patient must be experiencing pain as a result of the vein disorder.
• Failure of conservative measures. Other methods of treatment, such as compression hose, have failed to provide adequate relief.
• Vein size. Bulging veins larger than 4 mm are often considered medically significant.
• Complications. Complications such as phlebitis, bleeding veins, leg swelling and leg ulceration make it more likely an insurance company will consider treatment medically necessary.

According to Medicare, medically necessary signs and symptoms include pain, swelling and ulceration. In these cases, after documentation of venous insufficiency by ultrasound, Medicare will usually deem endovenous ablation and ambulatory phlebectomy to be medically necessary.
As podiatrists, we do not perform these venous ablation procedures but we often refer venous ulceration patients to vein clinics and/or vascular surgeons. Therefore, it is important to be aware of the insurance guidelines so we can assist these patients if we feel they may benefit from a venous procedure.

It is important to initiate compression therapy as soon as possible in patients with venous ulcers unless it is contraindicated (for example, when these patients have associated peripheral arterial disease). According to Dr. Lingelbach, many of these patients who have venous ulcers should improve or heal their ulceration without venous ablation. However, if conservative therapy fails, we do not want to delay a venous procedure.

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Original Posted on Podiatry Today.