by AJ Riviezzo
United Healthcare just came out (on 4/1/2024) with a new Clinical UM Guideline effective April 1, 2024. Nice of them to give everyone notice! Noted below are some of the guidelines for this new policy (2024T0447MM) and the changes from the old policy.
Treatment of the Great Saphenous Vein and the Small Saphenous Vein are considered medically necessary when all of the following are present:
· Junctional Reflux must be present in these veins; or
· Ablative therapy for Accessory Veins only if related persistent Junctional Reflux is demonstrated after the GSV or SSV have been removed or ablated.
· Skin ulceration; or
· Documented episodes of frank bleeding of the vein due to erosion of/or trauma to the skin; or
· Documented Superficial Thrombophlebitis; or
· Documented Venous Stasis Dermatitis causing Functional or Physical Impairment; or
· Moderate to Severe Pain causing Functional or Physical Impairment
The Veins Size criteria are:
· The GSV must be 5.5mm or greater when measured at the proximal thigh below the saphenofemoral junction.
· The SSV or Accessory Veins must measure 5mm or greater in diameter immediately below the appropriate junction.
Duration of reflux must be greater than or equal to 500 milliseconds.
RF and Laser ablations are acceptable. VenaSeal, Varithena and MOCA are not acceptable technologies still.
All of the above is pretty much what was in the old policy. What is different is their Documentation Requirements section which essentially details what United Healthcare expects to see in the History and Physical. It is pretty standard information like diagnosis, history of prior treatment, signs and symptoms of the disease, disease impact on the patient’s Activities of Daily Living, and other normal documentation. There are two elements that stand out in this section. These are:
· Functional disability(ies), as documented on a validated functional disability scale, interfering with the ability to stand or sit for long periods of time
· Prior non-invasive treatments of the veins that have been tried, failed, or were contraindicated; include the dates, duration and reason for discontinuation
Which functional disability scale are you supposed to use? No one knows. United Healthcare has not produced said scale nor is it attached to the policy. Our take? They don’t know either. Someone added in language without knowing they do not own such a document. We recommend you ignore it for the time being. The elements for medically necessary treatment are outlined in the Coverage Rationale section of the Policy and the scale is not included in that section. Should that change, we will alert you.
As to prior non-invasive treatment, documenting this is appropriate. Has the patient been doing some version of conservative therapy? If yes, for how long? What have been the self-reported results? There is still no requirement for conservative therapy and we recommend you just abide by the medically necessity guidelines noted above. In short, nothing much has truly changed. Same medical necessity criteria, no new technologies are approved for use, and a bit of clarity on documentation requirements. A full copy of the policy can be found here: United Healthcare Policy.