Wiki Varicose Veins vs Venous Insufficiency

[rmjanowitz]

According to Medi-Cal (CA Medicaid) guidelines for custom compression stockings (A6549), a patient must have symptomatic venous insufficiency or lymphedema to meet the criteria for coverage.

Specifically:

Criteria
The recipient requires one or both of the following:
Custom made compression stockings to treat symptomatic venous insufficiency or lymphedema in one or both lower extremities (A6545 and A6549)

Per the documentation, the patient has bilateral varicose veins in the lower extremities (as well as a mention of some pain in both legs). The doctor is going with a Dx of I83.893. No mention of a diagnosis of venous insufficiency. As far as I know, someone can develop venous insufficiency from varicose veins, but varicose veins by itself doesn't mean a diagnosis of venous insufficiency. Is that the correct way of looking at this? Or would criteria written like this be referring to varicose veins as (definitionally) a type of symptomatic venous insufficiency? Specifically, varicose veins are caused by a weakening (insufficiency) of venous structures that allow blood to pool in the legs?

Any help would be great. I'm assuming if I bill this as authorized, it will be denied as non-covered due to Dx.

 

[sls314]

According to Medi-Cal (CA Medicaid) guidelines for custom compression stockings (A6549), a patient must have symptomatic venous insufficiency or lymphedema to meet the criteria for coverage.

Specifically:


Per the documentation, the patient has bilateral varicose veins in the lower extremities (as well as a mention of some pain in both legs). The doctor is going with a Dx of I83.893. No mention of a diagnosis of venous insufficiency. As far as I know, someone can develop venous insufficiency from varicose veins, but varicose veins by itself doesn't mean a diagnosis of venous insufficiency. Is that the correct way of looking at this? Or would criteria written like this be referring to varicose veins as (definitionally) a type of symptomatic venous insufficiency? Specifically, varicose veins are caused by a weakening (insufficiency) of venous structures that allow blood to pool in the legs?

Any help would be great. I'm assuming if I bill this as authorized, it will be denied as non-covered due to Dx.

I see in the Medi-Cal documentation that "Authorization and Restrictions HCPCS codes A6545 and A6549 always require authorization (TAR required)."

Page 5: https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/orthoauthortho.pdf

What diagnosis was used to get the authorization approved? I agree that it doesn't look like Varicose Veins would be a covered indication. Was that the diagnosis used on the pre-auth request, or did the provider use something else?

 

[rmjanowitz]

So, here comes the messy part. The patient has a Medicaid integrated plan. The health plan says they follow Medi-Cal guidelines. They are responsible for payment.

However, the patient is assigned to an IPA, who is responsible for authorizations. So, the patient saw their IPA doctor, who put in for the auth with the varicose vein dx. The IPA has authorized it.

Now I'm stuck in this situation where the IPA has authorized a service that is not covered by the health plan. In my opinion, per Medi-Cal guidelines, this is not a covered service for this dx, therefore the IPA should be responsible for the services. But, they are adamant that these services are the responsibility of the health plan because of the DOFR in place.

Neither the health plan or the IPA will sit down and look at the guideline to tell me if this is covered or not. The IPA won't because they're not financially liable (from their perspective) and the health plan won't because they are not responsible for anything prior to us billing for services.

The dx on the auth from the IPA is I83.893.