In today's age of beauty and fashion, men and women are seeking ways to eliminate the ugly varicose veins they tend to get with age, weight and heredity. While this might seem like an optional, cosmetic surgery, many people in their twenties and older frequently suffer from swollen and painful legs as a result of varicose veins. In advanced cases, patients can also experience leg ulceration, skin breakdown, superficial phlebitis and, in rare instances, bleeding.

There are a multitude of causes that contribute to a patient's inclination to get varicose veins. Typically, physicians prescribe basic solutions, such as compression stockings that squeeze the leg and may alleviate many of these symptoms. But, these solutions don't work for all patients.

The stockings don't make the twisted-looking and bulging veins go away, and, oftentimes, patients find them difficult to put on, hot to wear or not suitable for their lifestyle. If, after several weeks, patients are not getting what they want from compression stockings, they are probably going to consider surgery. Why? With varicose veins, the damaged veins cannot pump blood back to the heart, which causes adverse patient symptoms. Surgery either removes the vein and its tributaries, or cauterizes the vein to prevent blood flowing through it. Yet, except in well-documented cases, most healthcare plans consider varicose vein surgery cosmetic.

In order for varicose vein surgery to be covered:

A patient's physician needs to conduct a physical exam, as well as document the patient's history.

The patient must follow the conservative treatment plan and wear the compression stockings for several weeks.

The physician must track all of the patient's general health, medical history, symptoms and tried treatments to help prove the need for surgery. If the patient rejects the conservative treatment or if further proof is needed, a physician can conduct an ultrasound to measure the speed of blood flow and observe the structure of the patient's veins and determine the reflux (backflow) of blood. This test can also determine if there are other conditions affecting the leg and provide the insurance carrier the medical evidence needed to cover the surgery. Another advantage of this approach, is that it eliminates those patients with spider veins looking for payers to cover a procedure that's purely non-medical and cosmetic.

For a case study on how one organization uses an IRO for medical necessity reviews, view our Ensuring Quality/Determining Necessity case study.