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What Defines Medical Necessity
by Cheryl Nash
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There is always some confusion on what exactly defines ‘medical necessity’ for sclerotherapy. Like all treatments in Phlebology, this answer can really depend on who you are talking to. More specifically, which payer you are working with. As in all things in this business, the individual requirements are as different as they can possibly be. I will try to focus on the similarities instead.
The first requirement that tends to be standard among all payers is that the patient needs to exhibit continuing symptoms. If the patient is asymptomatic, then no further treatment is indicated according to most payer guidelines. An example from Trailblazer Medicare LCD guidelines: Symptomatic improvement is the primary goal and indicator of a satisfactory outcome. Documentation of recanalization or failure of vein closure without recurrent signs and symptoms does not necessarily indicate a need for additional injections. And from Aetna’s clinical policy bulletin: Additional sets of injections of sclerosing solution are considered medically necessary for persons with persistent or recurrent symptoms. Of course there will be variances in this requirement from differing payers, but the theme seems to be the same for the most part.
The other requirement for injections ties into proving that the veins that are treated are not spider veins. Most payers determine this by vein diameter. The average size allowed by most payers is 3mm, but again, check the policy first! The size can differ from 2.5mm in Aetna’s policy, to as much as 5mm in Highmark BCBS’s policy. In either case having the documentation of size in the chart is key to being paid. If it is not documented most payers will deny as cosmetic, and this cannot be overturned without definitive proof in the records.
There are a few payers that do have an exception to the spider vein rule. If a patient has a spontaneous hemorrhage of a vein or capillary, there are a couple payers who will cover an injection billed with 36468, and 448.9 as the diagnosis code. From BCBSNC policy: The treatment of spider veins/telangiectasis (36468) will be considered medically necessary only if there is associated hemorrhage.
For services that are not considered covered by a particular plan, but are considered necessary by the provider for the best patient outcome, a patient can sign a waiver understanding that the injections are not going to be paid by their insurance and that they are willing to do the treatment anyway on a cash basis. For some plans, the waiver must be signed or the patient may not be billed. It is a good idea to do this with all patients just to have the record on file.
It is recommended to read the clinical guidelines that apply to your practice carefully to determine the exact requirements for performing sclerotherapy to ensure the most comprehensive treatment and billing is achieved.
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