Medical vs Cosmetic, What Does Insurance Require?
By: Brian D. Heeringa MD FACS RPhS
It is not uncommon for patients to have both medical and cosmetic vein disease. What is the difference? Most insurance plans cover treatment of varicose veins only if deemed “medically necessary”. Treatments that do not meet your policy’s criteria will be considered cosmetic. What do insurance companies consider medically necessary? Should you even attempt to get your insurance to cover your vein treatments? These are all common questions that we deal with on a daily basis. Sometimes the answers are obvious and other times the lines between medical and cosmetic vein disease are blurry. The answer to the question of whether or not your varicose veins meet criteria for medical necessity may depend not just on what your symptoms are, but on what your insurance policy states. This means that what is medically necessary for one policy could be considered cosmetic under a different insurance plan. In this article, I hope to help you determine what you may need to get insurance to cover your vein treatments and, whether or not attempting to do so is in your benefit or not.
First of all, most insurances plans will state that treatment of spider veins is not medically necessary. For this reason, most spider vein treatments are considered cosmetic. The exception being when a patient has bleeding from spider veins. Spider veins are the very fine (less than 1mm) red and blue veins on the skin surface. By way of contrast, varicose veins are larger (3mm or greater), ropy veins under the surface of the skin. Varicose veins will often bulge or protrude and appear as lumps. It is important to note however, that not all varicose veins are visible on the surface of the skin and often patients will have varicose veins under the skin and only visible spider veins on the surface. This is where an exam by a provider experienced in vein care can help you determine if there may be pathology under the skin that may meet medical criteria. For example, swelling and even ulcers are signs of advanced vein disease but these often happen in the absence of ropy varicose veins.
This leads us to the first criteria for medical necessity: symptoms. Not liking the appearance of a vein does not make it medically necessary, however, having symptoms typically does. Common venous symptoms are aching, heaviness, pain, throbbing, leg fatigue, frequent night time cramps, itching, swelling, and restless legs. Bleeding, pigmentation (a discoloration of the skin) and even ulceration are other potential presenting symptoms. I find that many patients do not realize how symptomatic they are until after their veins have been treated. The symptoms of venous disease come on slowly, often over many years, so patients falsely believe that their symptoms are just normal signs of aging. It is important to note however that your legs shouldn’t hurt or be tender. It is not normal to have tired or heavy legs on a daily basis. Likewise, your socks should not leave imprints on your ankles, that is a sign of swelling. If you have any of the above symptoms, you could have venous insufficiency and a work up for medical vein disease is indicated.
The next criterion that insurance companies typically require for medical necessity is venous reflux. This criterion make sense. Basically, the insurance providers are stating that they will not cover “fixing a vein” if it’s not broken. Blood should travel up the veins from the legs toward the heart, but gravity is always present pulling that blood back towards the feet. The veins in our legs have valves which should prevent backwards flow. If the valves do not work gravity pulls that blood back down the vein instead of up. That backwards flow is called reflux. The best way to determine if you have reflux or not is with an ultrasound, and to be accurate, that ultrasound should be done in a standing position. This criterion also excludes the treatment of spider veins as they do not make ultrasounds sensitive enough to determine reflux in such small veins.
The final criterion commonly found in most insurance policies regarding the medical necessity of vein care is a trial of conservative therapy. Essentially, your insurance company wants you to try doing things to improve your symptoms that do not involve any procedures. Conservative measures that you can do at home include, maintaining a healthy weight, walking, periodically elevating your legs above the level of your heart, calf raises and wearing compression stockings. In fact, most insurance policies specify that you must wear class 2 (medical grade or at least 20-30mm Hg) compression stockings for 6-12 weeks before they will cover treatments. I typically recommend all the above conservative measures to help with venous symptoms. Unfortunately, in my experience, while wearing compression stockings, leg elevation and walking all help, none of them provide lasting relief. That is, symptoms typically return shortly after the compression stockings are removed or as soon as you put your legs back down.
In summary, the three most common criteria needed for medical necessity are symptoms, venous reflux and a trial of conservative therapy.
Does this mean that everyone with symptoms should bill all of their treatments to insurance? The answer to this question will again depend on your policy, and on your deductible. For example, if you have varicose veins that are symptomatic and are likely to show reflux on an ultrasound but which could be easily treated with sclerotherapy and you have a high deductible plan, you may be better off treating and paying for this as a cosmetic procedure. I say this because the cost of an ultrasound and treatment are likely to be much less than what your deductible is. In these cases, you may save money by skipping the ultrasound and proceeding directly to treatments.
If on the other hand, you have met your deductible, this same scenario could ethically and legally be billed to your insurance as the veins are symptomatic and meet the policy requirements for medical necessity. Of course you should be examined by a physician to determine if you can skip the ultrasound or not. If the veins are small but overlie or drain the areas of commonly diseased veins you may have problems with one of the named superficial veins such as the Greater Saphenous Vein and if that is the case, sclerotherapy alone is unlikely to give long lasting results and an ultrasound would be indicated to determine the exact source of the problem. If after the ultrasound, your physician determined that an endovenous ablation is needed then those procedures have higher costs and thus it would likely be in your best interest to bill those to insurance and have them applied to your deductible.
It should also be noted that these are general criteria and each insurance policy can be different. It is important that you check with your insurance carrier to determine what your specific policy requirements are.
If you still have questions as to whether or not you have medical or cosmetic vein disease or both feel free to call our office. We offer complimentary cosmetic screenings and if at that time it is determined that you have medical disease you could be set up for a formal and thorough clinical evaluation and ultrasound if indicated.
For more information, give us a call at 231-946-1488 or email us at [email protected] Dr. Heeringa or one of his staff will personally respond to all email inquiries.