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General Venous Disease Questions

What are Spider & Varicose veins?

Spider veins are the small, thin, bluish-purple or red veins visible on the surface of the skin. Varicose veins are larger than spider veins, and are typically described as being “bulging” and/or “twisty.” They can be discolored, but are most commonly flesh colored.

What causes Spider & Varicose veins?

Most spider and varicose veins are the result of a condition called Chronic Venous Disease, or CVD. In order to understand how CVD causes spider and varicose veins, a basic understanding of the body’s circulatory system is helpful.

The heart is a pump that delivers “fresh” blood to the body. This “fresh” blood contains the fuel that the body needs to live-most importantly, oxygen and glucose. The heart pumps the “fresh” blood into the arterial system. As the “fresh” blood is delivered to the body, the “used” blood is collected in the venous system.

The venous system doesn’t have a pump attached to it like the arterial system does, and as a result, it is a low pressure system. To help the veins to carry the “used” blood back to the heart and lungs, they have one way valves inside of them. In CVD, some of these valves begin to leak. In the legs, this causes the “used” blood to drain more slowly, and can result in leg pain, swelling, restlessness, and prominent spider and varicose veins.

How Common is CVD?

Chronic Venous Disease (CVD) is very common. Over 30 Million people in the US suffer from CVD, although only 1.9 Million (about 6%) seek treatment each year. This low number is related to the fact that most people-patients and even their doctors-are not aware that new and much improved treatment options are now available.

One study estimates that by the time they reach  60 years of age, 72% of women and 43% of men will suffer from CVD.

What Increases my risk for CVD?

There are several factors that can increase your risk of developing Chronic Venous Disease (CVD), including:

  • Family History of CVD
  • Increasing age
  • Obesity
  • Pregnancy
  • Prolonged sitting or standing
  • Prior injury or surgery
  • History of blood clot in a vein

While CVD is more commonly found in women, men can be affected as well. One study estimated that by the age of 60 years, 72% of women and 43% of men will have some degree of CVD.

What symptoms of CVD should I look for?

Patients suffering from Chronic Venous Disease (CVD) can present with a variety of leg symptoms, including:

  • Pain/aching/cramping that gets worse as the day goes on
  • Heaviness/fatigue
  •  Swelling
  • Itching, with or without a rash
  • Restlessness
  • Prominent veins (spider or varicose)
  • Darkening of the skin
  • Ulcerations

Should I be evaluated for CVD?

If you suffer from any combination of the above signs and symptoms, and you feel that these are preventing you from living the kind of life that you want to live, you should seek treatment by a qualified vein specialist.

At McQuaid Vein Specialists, we will collect your medical history and perform a physical examination. If we feel that your signs and symptoms are likely to be related to Chronic Venous Disease (CVD), we will perform a non-invasive duplex ultrasound study on your legs. All of that information will then be reviewed and a customized treatment plan will be developed, using a combination of the treatment modalities available to us, to address your condition.

How is CVD treated?

In the past, Chronic Venous Disease (CVD) was treated with conservative measures-essentially leg elevation and compression therapy-until the patient’s condition got severe enough to warrant surgery. Vein stripping was the surgical procedure of choice. It was a painful procedure which required either regional or general anesthesia in a hospital setting, and frequently required post-operative hospitalization.  There was a significant amount of post-operative discomfort, and it took a long time for patients to recover. Vein stripping procedures were often complicated by nerve injuries, and recurrence/failure rates were high.

Thankfully, much has changed in the management of CVD over the past 10-15 years. At McQuaid Vein Specialists, we are now able to treat CVD in the office setting, with minimally invasive procedures performed with local anesthesia. Once the diseased veins are identified by a non-invasive ultrasound study, we treat them by shutting them down, using a combination of the modalities that we have available to us. Eventually, the treated veins turn into scar tissue and are absorbed by the body. Once the diseased veins are shut down, the body redirects the “used” blood to other, healthy veins, and the blood is able to drain from the leg more efficiently, as it is supposed to.

Evaluation & Pre-Operative Questions

What will happen at my first visit?

During your initial visit, you will speak with the physician and have a physical examination. If indicated, an ultrasound will be ordered by the physician to be reviewed after your consult. This can be scheduled the same day as your visit but may not always be available.
Medical grade compression (20-30 mmHg) stockings may be prescribed.

A follow up appointment is typically scheduled based on the requirements dictated by your insurance company. Most insurance companies require a 3 to 6 month trial of conservative measures before they will approve definitive treatment of your insufficient veins.
In some extreme cases, a patient may qualify to have procedures performed without the conservative measures requirement. This would be outlined in your insurance policy criteria. Typically, patients must have some kind of ulceration or bleeding to qualify for this exemption but it can vary, based on your insurance.
After reviewing your ultrasound, your physician will establish your personalized treatment plan. A member of our clinical team will call you and go over the recommended procedures. This process can sometimes take up to two weeks.

What are "conservative measures?"

“Conservative measures” would include measures such as exercise, leg elevation and medical grade compression stocking use. These measures can help to decrease the symptoms associated with Chronic Venous Disease (CVD), and may also help to slow down the progression of CVD, but they will not effectively treat the underlying cause.

Despite that fact, most insurance companies require proof of 3 to 6 months of medical grade (20-30mmHg or higher) compression stocking use. To document this, we ask that you bring a copy of your receipt for your stockings for our records.

Does past stocking use count?

As long as you have proof of purchase for compression that is at least 20-30 mmHg, we should be able to submit this information to your insurance company with our pre-determinations.

What vein treatments do you offer?

Thermal Ablation:

  • Radiofrequency Ablation (RF)
  • Endovenous Laser Ablation (EVLT)

Chemical Ablation:

  • Ultrasound Guided Sclerotherapy (USGS)
  • Injection Sclerotherapy

Other Modalities:

  • Ambulatory Microphlebectomy
  • Thermo coagulation (Angie)

Can I just treat my spider veins?

Most patients with spider and varicose veins have underlying venous disease. We want to provide our patients with the most optimal treatments for the best possible long-term results. Therefore, McQuaid Vein Specialists require that all patients have a detailed ultrasound of their leg veins performed after their initial consultation to determine the extent of venous disease. If this ultrasound shows no underlying issues, cosmetic vein procedures may be considered.

How quickly can I get treatment?

Our goal is to follow insurance company guidelines in order to get your procedures approved. We will not schedule patients for any procedures without authorization on file from your insurance company. If you choose to go outside of your insurance and have procedures performed as a cash pay expense, you may schedule at any time but will be required to pay for all procedures in advance. Estimates are provided upon request.

Based upon the limitations set by your insurance company and the necessary process for authorizations, we may or may not be able to perform your procedures by the end of the year. Please understand that we have to schedule patients in the order that authorizations are received.

The end of the year is the most popular time for scheduling, as most patients have met most or all of their deductible. So, we recommend scheduling when you receive a call from us stating that your procedures are approved. Any delay in scheduling may result in the inability to have your treatment plan completed in the desired time frame.

Do you offer sedation?

We most commonly offer Valium to our patients in 5-20mg doses, depending on your tolerance and other health factors. Sometimes Versed is also offered, on a case-by-case basis.

Sedation is not required for the procedures. Although, we highly recommends taking sedation for thermal ablations and significant phlebectomies.

Although sedation is not used for every procedure, a driver is still required on days when thermal ablations and phlebectomies are to be performed.

Post-Operative Questions

How long do I wear the stockings?

The amount of time you need to wear the compression stockings after a procedures depends upon the procedure that was performed. Please double check the post-op instructions given to you after your procedure.

If you can’t find the post-op instruction sheet, they can be found here.

What can I take for pain?

The prescribed anti-inflammatory medication will help reduce inflammation following your procedures, and this will help with discomfort.

Please refer to the post-op instructions for further clarification.

When can I exercise again?

Low impact exercise in the form of walking is encouraged, starting the day of the procedure

Restrictions: for 1 week after any procedure

  • No High Impact (Running, weight lifting, any type of pounding on the leg) or straining
  • No lifting over 20 lbs

Allowed:

  • Yoga (except hot yoga)
  • Elliptical
  • Treadmill
  • Speed walking (no running or jogging for the first week)

When can I go swimming?

You can swim after 1 week in your own pool and 2 weeks in a public pool.

What about sun exposure?

Sun exposure is not recommended without heavy sunscreen. The sun can cause darkening of the skin on areas that are bruised or discolored after procedures.

How soon can I travel?

While we recommend a 3 month post-operative healing time before extensive travel, we understand that this is not always possible. We require at least 2 weeks healing time before extensive travel, and if you do have to travel, you will need to follow certain precautions. Wear your compression stocking, stay well hydrated (avoiding caffeinated beverages), and ambulate often. Stop at least once each hr if traveling by car to walk for 5-10 minutes. If flying, the same precautions apply, and you can either walk around the cabin or flex and relax your calf muscles regularly during the flight. This encourages blood flow out of the leg, and lowers risks of blood clots. Flights over 3 hours are not recommended for 1st month following thermal ablations.

Insurance/Billing Questions

Is this covered by insurance?

There is a common misconception that the treatment of venous disease is considered purely cosmetic, and therefore not covered by health insurance. While that is true for the treatment of spider and reticular veins (the small, blue/purple veins close to the surface of the skin), those treatments are only a small component of the treatment of venous disease. Patients who have spider and reticular veins typically have more significant underlying venous problems which are causing those surface veins to become more noticeable. Fortunately, most insurance plans do cover the procedures that treat those underlying problems.

Why were my procedures denied?

There are many reasons why insurance companies may deny some/all of your recommended treatments. Usually, patients receive authorization/denial letters before our office does. We encourage you to read through your letter, which should tell you exactly why you were denied for some/all of your procedures. We have provided a short list of the most common reasons for denial:

Thermal ablation (RF, EVLT) Denial:
Vein Size/Reflux Time – Insurance companies usually outline a minimum “vein size” or “reflux time” in their medical policy criteria (usually found online) to determine if your procedures are considered “medically necessary” or “cosmetic” in nature. If your ultrasound did not show your veins to meet the requirements, they may deny you treatment as not being “medically necessary” and therefore considered “cosmetic.”
Example: Your policy may state that a vein diameter of 5.5mm and/or reflux (backwards flow of blood through a leaky valve) of at least 1000 milliseconds are required for treatment of an insufficient vein to be considered “medically necessary” and anything below those parameters are considered cosmetic. So, if your vein was 5 mm with 800 milliseconds reflux time, treatment of that vein would not be covered by your insurance, until the condition worsened.

Tributary/perforator veins – Some insurance companies will not cover ablations for tributary or perforator veins. Usually, they will provide coverage for the ablation of the Great Saphenous Vein (GSV), Small Saphenous Vein (SSV), and Anterior Saphenous Vein (ASV), if they meet policy criteria.
Phlebectomy Denial:

Vein Size – Even though you may have bulging veins that are symptomatic, they may not meet the requirements set by your insurance company for this procedure. Typically, this would mean that your vein sizes did not meet the minimum standard for medical necessity.

Six Week Observation Required – Some insurance companies (typically Blue Cross & Blue Shield) require that patients complete their initial ablation procedures, and then come in for a six week follow up in order to approve the next steps in the treatment plan.
The reasoning behind this is that the initial ablation procedures may alleviate the need for further treatments. So, we have to document at your six week follow up whether or not your legs are still symptomatic and the remaining diseased veins are in need of additional treatment.

THIS FOLLOW UP IS TO BE COMPLETED AFTER YOUR SECOND ABLATION. IF WE TRY TO SUBMIT AFTER YOU HAVE ONLY COMPLETED ONE OF THE TWO ABLATIONS IT MAY CAUSE YOU TO BE DENIED FOR THE REST OF YOUR TREATMENT PLAN INDEFINITELY.

Ultrasound Guided Sclerotherapy (USGS) Denial:
Six Week Observation Required – Some insurance companies (typically Blue Cross & Blue Shield) require that patients complete their initial ablation procedures, and then come in for a six week follow up in order to approve the next steps in the treatment plan.
The reasoning behind this is that the initial ablation procedures may alleviate the need for further treatments. So, we have to document at your six week follow up whether or not your legs are still symptomatic and the remaining diseased veins are in need of additional treatment.

“Recommended procedure is considered to be experimental in nature” – Some insurance companies may state that they consider the recommended procedures to be experimental in nature and not cover them.

Can you just do what is approved?

Although it is strongly recommended that you complete all recommended treatments outlined by your physician, you may choose to not complete some non-covered procedures, based on your insurance authorizations/denials. We encourage you to carefully read the documents mailed to you by your insurance company regarding your approved/denied procedures. Should you have any questions regarding omitting any treatments, you should address these issues at your pre-operative appointment.

If you have any questions regarding your authorizations/denials and potential fees for services, please contact our insurance department by phone Monday thru Friday 8:00am-5:00pm or email insurance@mcquaidvein.com.

Can you do a peer to peer review?

We have tried numerous times in the past to perform peer-to-peer reviews and appeals on decisions concerning medical policy guidelines and medical necessity. Sometimes we are able to successfully explain why the recommended treatments are medically necessary, but this is not always the case. If, based on our experience, we feel that there is a good chance of success, we will perform a peer to peer review.

We encourage you, as a patient and consumer, to call your insurance company and inquire as to why these things were denied and let them know that your condition is “affecting your quality of life”. Sometimes by filing your own appeal, you can get them to change their decision.

What if my insurance changes?

If change happens during the Conservative Care Waiting Period:
You would not have to start over on your waiting period for wearing your stockings. It would just change to the waiting period required by your new insurance carrier.
So, if you previously had BCBS (4 months waiting period) and switched to Cigna (6 month waiting period) we would have to move your insurance required follow up to a date 2 months later than planned

If change happens during the treatment plan:

  • If you have to change insurance companies for any reason during the course of your treatments, we need to know about this immediately.
  • All future procedures would need to be cancelled and we would need to submit to your new policy for authorization.
  • Failure to notify us will result in a denial in claims and ultimately reflect charges in full to the patient.

Celebrex was denied-other options?

Most insurance policies have a “step program” in place that would require you to try a less expensive prescription prior to Celebrex. You would have to try an alternative medication, such as Lodine, first. If that medication is ineffective for you, then you may be able to get Celebrex approved at a later time. We may attempt authorization and, in the event it is denied, we can call in a substitute medication.

Patient Testimonials

"Over the previous three to four years, Brad had experienced problems in his left leg, including aching, swelling, itching, hair loss, and skin discolorations and sores. He came to McQuaid Vein Specialists for an evaluation and had his…" -- Brad G.