use follow up and ultrasound from: 3/29/23

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: Anirban De
Date of Birth: 1/21/76
Date: 4/4/23
RE: DETERMINATION OF MEDICAL NECESSITY FOR CHRONIC VENOUS
INSUFFICIENCY REQUIRING VARITHENA INJECTIONS OF RESIDUAL
INCOMPETENT SAPHENOUS VEIN SEGMENTS AND SAPHENOUS TRIBUTARIES,
FOLLOWING PREVIOUS SAPHENOUS ABLATION

Dear Sir/Madam,
The purpose of this letter is to certify that the above-named patient suffers from varicose
veins with pain and has chronic venous insufficiency. (ICD-10 codes I83.813 and
I87.2). This condition requires medical attention and treatment.
The required treatment is as follows: Varithena injections of residual incompetent
saphenous vein segments and saphenous tributaries, following previous saphenous
ablation. Compression stockings are also required for a short time after treatment,
during postoperative care. The expected result is decreased symptoms and return to
normal tolerance of activities of daily living.

This case requires medically indicated and necessary treatment for this patient’s chronic
venous disease. Left untreated, the patient’s symptomatology will never be alleviated,
normal venous function will not be re-established, and the possibility of eventual
complications is increased. There is no expectation of hospitalization, and the
procedures are to be performed in a medical office as an outpatient basis. The patient
is expected to return to normal activities the following day after each procedure.

History & Presentation: The patient has a many year history of bilateral lower extremity
varicose veins with swelling and skin pigmentation. He has been doing conservative
therapy for more than the past year, including the daily use of compression stockings
measuring 20 to 30 mm Hg, anti-inflammatory medications, leg elevations, exercises,
and weight management. He has previously undergone endovenous laser ablations of
the left small saphenous vein from the sapheno popliteal junction and the left great and
anterior accessory great saphenous veins from the sapheno femoral junctions as well
as the right great saphenous vein from the sapheno femoral junction. He continues to
have bilateral lower extremity pain and reversible calf edema and difficulties with
activities of daily living, including with his job in a store which requires prolonged
standing. He has bilateral lower extremity varicose veins measuring greater than 4 mm
in diameter and skin pigmentation along the calf. Ultrasound venous duplex
examination performed on 3/29/23 showed severe venous insufficiency of the left great
saphenous vein in the calf measuring up to 5 mm in diameter and with 1 second of
reflux, the left cranial extension of the small saphenous vein measuring 6.5 mm in
diameter and with 1 second of reflux, and the right great saphenous vein in the calf
measuring 4.7 mm in diameter and with 1 second of reflux.

The patient needs certification of medical necessity for the following procedures:
- Varithena injections of the severely left great saphenous vein in the calf
measuring up to 5 mm in diameter and with 1 second of reflux, the left cranial
extension of the small saphenous vein measuring 6.5 mm in diameter and with 1
second of reflux, and the right great saphenous vein in the calf measuring 4.7
mm in diameter and with 1 second of reflux, following previous ablations of the
bilateral great saphenous veins from the sapheno femoral junctions (CPT 36466-
LT and 36465-RT)

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

Ronald Lev, MD

This letter may contain confidential health information that is privileged and legally
protected from disclosure by the Health Insurance Portability and Accountability Act
(HIPAA). This information is intended only for the use of the individual to which this
letter is specifically directed. If you are not the intended recipient, you are hereby
notified that reading, disseminating, disclosing, distributing, copying, acting upon or
otherwise using the information contained in this letter is strictly prohibited. If you have
received this information in error, please notify the sender immediately at 212-204-6501
and destroy the letter.