To: Predetermination From: Mark F.

Fax: 1859-455-8650 Pages: Incl. pages

Patient: Adenta small Date: 03/14/2023

ID #: W218355175

TIN: 26-4431318 NPI #: 1518024678

 Comments: If you have any questions please contact me at 862-243-7244.

 Please review the following cpt codes: 37238, 37252, 36012, 76937, 75820,
37253 x 3
Please review the following diagnosis code: i87.1

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Advanced Varicose Vein Treatments of Manhattan
Ronald Lev, MD
111 John Street, Suite # 1450
New York, New York 10038
phone: 212-204-6501 fax: 646-369-1010

Patient: Adante Small

Date of Birth: 5/3/62
Date: 3/14/23
RE: DETERMINATION OF MEDICAL NECESSITY FOR VENOGRAPHIC AND
INTRAVASCULAR ULTRASOUND EVALUATION OF THE IVC, ILIAC AND COMMON
FEMORAL VEINS, AND POSSIBLE ILIAC VEIN STENT PLACEMENT FOR
TREATMENT OF MAY THURNER SYNDROME (ICD-10 code: I87.1)

History & Presentation: The patient has a progressively worsening history of bilateral
lower extremity venous claudication and lower extremity edema. He went to the
emergency room for this a few weeks ago. He has CEAP class 2, 3, and 4A vein
disease with varicose veins, edema, and skin pigmentation. Venous clinical severity
score is 11. Venous ultrasound duplex examination showed narrowing of the left
common iliac vein and May Thurner Syndrome is suspected.

The required diagnostic procedure is as follows: intravascular ultrasound and

venography and venous stent placement:

ultrasound guidance for venous access 76937

venous stent placement 37238
intravascular ultrasound + 37252 and +37253 x 3
selective catheter placement
Venography 75820

Thank you for your consideration and please call me at 212-204-6501 if you have any
questions regarding this patient.

Ronald Lev, MD

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