What Evidence Is There For Compression Prior

To Insurance Approval?

VEITHsymposium
49th Annual Symposium on Vascular and Endovascular Issues
SESSION 69: VENOUS SOCIETAL AND GOVERNANCE
Thursday, November 17, 2022
1:57 PM - 2:02 PM
Omar L. Esponda MD RPVI RPhS
Plate XIII

Translation
Thou shouldst bind it with [fresh] meat [the first day] (and) treat
afterward with grease, [honey] (and) lint every day until he recovers.

Bandages were applied for two purposes:

• for covering and keeping effectively in place the medicaments
prescribed
• for mechanically retaining in position and protecting while healing
the ruptured tissue or the broken bone of the injury
Compared with no compression, the evidence suggests that:
• people wearing compression bandages or stockings probably
experience complete ulcer healing more quickly; and

• more people treated using the compression bandages or

stockings are likely to experience complete ulcer healing within 14 studies (1391 people, average age: 70.1 years)
12 months. that lasted on average for 12 weeks
Compression therapy
• Proven treatment strategy in:
• Managing venous ulcers (Zimmet S. 1999)

• Acute management of deep venous thrombosis (Partsch H. 2000)

• Reducing symptoms of post-thrombotic syndrome (Prandoni P. 2004)

• Reduce occupation related edema (Partsch H. 2004)

• Providing relieve from symptoms of venous hypertension (Ramelet AA. 2002)

Schul MW, King T and Kabnick LS. Inequalities of health

insurance guidelines for the treatment of symptomatic varicose
veins. Phlebology 2014; 29: 236-246.
• There isn't enough evidence that compression stockings are
effective as the only and first treatment for varicose veins in
people without healed or active venous ulceration.
13 studies with 1021 participants
• There were no definitive results from the included trials with varicose veins without healed
indicating the optimal duration of treatment or pressure of or active venous ulceration

compression stockings.
 What Evidence Is
There For
Do compression stockings… Compression Prior
To Insurance
Approval?

• improve anatomical closure of vein before ablation?

• decrease risk of adverse events prior to ablation of vein?

• reduce pathologic reflux in vein after weeks to months of use?

• stop progression of chronic venous insufficiency?

• reduce varicose vein burden prior to intervention?

What Evidence Is There For Compression
Prior To Insurance Approval?

No randomized controlled studies or meta-analyses

have shown a significant advantage from using
compression stockings before intervention.
“We could not approve
coverage of this service
because the member did not
meet the medical necessity
criteria required for
coverage of endovascular
ablation...”
What Evidence Is There For Compression
Prior To Insurance Approval?

The problem is not compression stockings as we know the limitations of this therapeutic device.
What Is Medical Necessity?
• Medicare defines “medically necessary” as health care services or
supplies needed to diagnose or treat an illness, injury, condition,
disease, or its symptoms and that meet accepted standards of medicine.

• We like to think that “Medically necessary” or “medical necessity”

means health care a prudent physician, using professional standards and
judgment, would give a patient.

• Medical necessity only describes the coverage that is offered under a

benefit plan.
National Association of Insurance Commissioners NAIC
UNDERSTANDING HEALTH CARE BILLS: WHAT IS MEDICAL NECESSITY?
What Is Medical Necessity?
• The way the health plan defines medical necessity impacts how it
decides which health care services it will cover for.

• Medical necessity is defined by the insurer through its medical policy.

• Each insurer may have a definition of “medical necessity” for services

within their laws or regulations.

National Association of Insurance Commissioners NAIC

UNDERSTANDING HEALTH CARE BILLS: WHAT IS MEDICAL NECESSITY?
Inconsistency
• Medicare administrative contractors (MACs) and the Centers for
Medicare & Medicaid Services (CMS) sometimes develop policies to
limit Medicare coverage of specific items and services.

• MACs issue local coverage determinations (LCDs) that limit coverage

for a particular item or service in their jurisdictions only.

• This can lead to State-by-State variation in Medicare coverage for

similar items and services.

Local Coverage Determinations Create Inconsistency i

n Medicare Coverage OEI-01-11-00500
Medicare Administrative
Contractor (MAC)
Jurisdictions
 Nordian Healthcare Solutions, LLC
 Novitas Solutions, Inc
 Wisconsin Physician Service Insurance
Corporation (WPS)
 National Government Services, Inc
 First Coast Service Options, Inc VIRGINIA
(3 months)
 Cahaba Government Benefit Administrators graduated
 Palmetto Government Benefit compression
Administrator stockings

 NHIC, Corp CALIFORNIA

(6-8 weeks) weight Local Coverage
 CGS Administrators, LLC
reduction, periodic leg Determinations (LCD)
elevation, graduated
compression stockings
Local Coverage Determination (LCD)
Medicare will consider interventional treatment of varicose veins
medically necessary if the patient remains symptomatic after a six-week
trial of conservative therapy.

The components of the conservative therapy include, but are not

limited to:
• weight reduction,
• a daily exercise plan,
• periodic leg elevation, and
• the USE OF GRADUATED COMPRESSION STOCKINGS.
Medicare defines “medically necessary” as health care
services… that meet accepted standards of medicine.

Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose
veins and associated chronic venous diseases: clinical practice guidelines of
the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg
2011; 53: 2S-48S.
 •Surgical treatment results in
better relief of symptoms
compared to conservative therapy.

•Relief of symptoms after

conservative therapy predicts
better outcomes of surgical
treatment.

Welch HJ, Schul MW, Monahan DL, et al. Private payers'

varicose vein policies are inaccurate, disparate, and not
evidence based, which mandates a proposal for a reasonable
and responsible policy for the treatment of venous disease. J
Vasc Surg Venous Lymphat Disord 2021; 9: 820-832.
In Conclusion
• Evidence for compression stockings benefit prior to insurance
approval for definite treatment of venous insufficiency in patients
with CEAP 3 and below continues to be non-existent.

• Insurers need to be consistent in defining medical necessity, therefore

a national coverage determination with true accepted medical
standards is the only reasonable alternative.
“I believe, and I tell patients this, that the payers are hoping some patients will go
away and not come back for an intervention. And of course, most payers don't
cover stockings.”
HW