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MVI News
Dr Benson Among First In Nation To Achieve Board Certification In Phlebology
Dr. Peter Benson, MD President of MVI, after being the first physician in the U.S. to officially change his specialty to
Phlebology in November 2005, has now become one of the first ever physicians to become board-certified in Phlebology.
The American Board of Phlebology recently released the names of the names of those physicians who had taken and passed the
inaugural board examination. Dr. Benson is one of only 248 physicians in the country to have acheived this accomplishment.
Dr Benson Appointed New Chairman of Coding & Reimbursement Committee
Dr. Benson was recently appointed to be the new Chairman of the American College of Phlebology's Coding and Reimbursement
Committee. The committee advises the ACP Board of Directors on matters relating to insurance reimbursement. Committee
members also assist member physicians with proper coding of phlebology procedures and provide educational sessions on
reimbursement issues for phlebologists in the U.S. and abroad. As one of the nation's leading experts on insurance reimbursement
for vein disease, one of Dr. Benson's chief goals for his tenure as Chairman is to improve access to vein treatment by working
with insurance companies to eliminate medical necessity requirements that do not improve the patients quality of life but
rather just stand as barriers to treatment.
Leigh Ann Joins The MVI Staff
Leigh Ann
Glomski has joined MVI as a medical assistant. Now that she has completed several months of training
she will be assisting Dr. Benson with endovenous laser ablation and sclerotherapy in the Gaylord and Traverse City offices.
Dr Benson Earns Second Term on Committee
Dr. Benson was reappointed to the American College of Phlebology's Coding and Reimbursement Committee for a second
term. The committee advises the ACP Board of Directors on matters relating to insurance reimbursement. Committee
members also assist member physicians with proper coding of phlebology procedures and provide educational sessions on
reimbursement issues for phlebologists in the U.S. and abroad.
Dr. Benson Becomes The First Phlebologist in the United States
In November of 2005, the American Medical Association officially recognized Phlebology as a distinct sub-specialty.
This specialty in vein treatment has existed in Europe for over 50 years. When Dr. Benson contacted the AMA to
seek that designation, he learned that he was the first US physician to be added to the AMA registry in the new specialty
of Phlebology. As of October 1, 2006, the AMA reports that Dr. Benson is still the only Phlebologist in the registry
from the state of Michigan. Addendum: As of May 1, 2008 the AMA now lists one other Phlebologist in the State of Michigan
(in Novi).
Dr. Benson Creates Blue Cross Blue Shield (BCBS) Database for the ACP
As part of his work with the Coding and Reimbursement Committee of the American College of Phlebology, Dr. Benson
created a database which brought all 65 medical policies together in one place. Somewhat suprisingly, while
Blue Cross markets to the public as thought it is one big nationwide plan, the various BCBS plans vary greatly in how they
cover or don't cover varicose vein treatment. This creates a difficult situation for both patients and their doctors
when trying to determine if a particular patient has coverage for treatment or whether the plan may require a patient to try
other treatments before allowing EVLA or sclerotherapy. Dr. Benson has brought all of these together into a spreadsheet
giving a doctor one click access to the medical policy of any Blue Cross Blue Shield carrier. For example, if a patient
in Michigan works for a large company who has their headquarters in another state, they may not have BCBS of Michigan.
Rather, they may have Anthem BCBS. Anthem BCBS has much different requirements than BCBS of Michigan does. With
the spreadsheet a doctor can click on the Anthem BCBS link and be taken directly to the web page that shows the Anthem medical
policy for coverage of Endovenous Laser Vein Ablation (also known as Endovenous Laser Treatment(EVLTtm). The spreadsheet has been published on the ACP website for access by member physicians.
Dr. Benson Speaks at 19th Annual ACP Congress
Dr. Benson was an invited lecturer at the 2005 American College of Phlebology 19th Annual Congress
in San Francisco, November 9 - 13, 2005. Dr. Benson spoke on insurance and reimbursement issues with regards to
vein treatment procedures. Dr. Benson serves as a member of the ACP's Coding & Reimbursement Committee and is actively
involved with improving insurance coverage for varicose and spider vein treatment. In addition to assisting his own
patients with securing insurance coverage for varicose vein treatment, Dr. Benson also advises and trains other physicians
from all over the U.S. on the optimum methods of coding and documentation to obtain insurance reimbursement for medically
necessary vein treatment.
Vein Surgery - Outstripped by New Methods?
Among the original research that was presented at the Annual Congress of the ACP were 2 studies showing that
the failure rate of vein ligation & stripping is much worse than previous known. In these studies, up to 66% of
patients who underwent vein ligation and stripping (conventional varicose vein surgery) had recurrence of their vein disease
(neovascularization) in 5 years or less. A small group of patients had evidence of new vein growth (neovascularization) within
2 months after surgery.
By comparison patients who underwent Endovenous Laser Vein Ablation (EVLA) had a zero (0%) percent incidence
of neovascularization and after 5 years only 6% to 8% of patients had clinical return of their vein disease. A survey
showed that vascular surgeons who perform endovenous laser vein ablation did a surgical ligation in addition to the laser
treatment in about 25% of patients while Phlebologists did not do surgery in any of their EVLA patients.
The study showed that the patients who were treated by vascular surgeons had no better results despite having an additional
surgical procedure done. By comparison, however, the patients who underwent surgical vein ligation had a higher complication
rate, had higher expenses, and missed much more work time. Dr. Benson, an AMA registered Phlebologist,
does not do vein ligation on any of his patients. In the rare instance (about 1 to 2 times/year), that a patient is
not a candidate for non - surgical methods, Dr. Benson will refer to a vascular surgeon.
Chelle Attends 19th Annual ACP Congress
Michelle (Chelle) Zann, L.P.N. attended the 19th Annual Congress of the American College of Phlebology,
November 9 - 13, 2005 in San Francisco. During the conference Chelle participated in a full day course focused on Venous
Ultrasonography & Vein Mapping as well as numerous other seminars on endovenous laser vein ablation, visual sclerotherapy,
and ambulatory phlebectomy. She also observed a live patient demonstartion of Ultrasound-guided Sclerotherapy.
Chelle got a good exposure to some of the current research being presented, but still managed to squeeze in a few minutes
to snap a few photos the sea lions at Pier 39 in the evening.
Sotradecol Approved
Sodium Tetradecyl Sulfate has long been the preferred agent for sclerotherapy. However, for the last four
years it could only be purchased in the U.S. from compounding pharmacies or imported . The FDA has recently approved sale
in the U.S. of Sodium Tetradecyl Sulfate (Sotradecol) from Canadian manufacturer Bioniche Pharma thereby alleviating the problems
with supply. The agent commonly in use by Dermatologists for spider vein treatment is hypertonic saline (not FDA
approved for sclerotherapy, very painful, not very effective for large spider veins, and totally ineffective for
varicose veins), and polidocanol (not FDA approved in the US for any indication). In Europe,
usage is about 50/50 for polidocanol and Sotradecol. Polidocanol appears to be more likely to cause formation of matting(nets
of small veins) than other agents. In my opinion, polidocanol should not be used in the U.S. on any patient with
Medicare or anyone who is submitting a claim for insurance coverage of treatment until it receives FDA approval. We
feel very comfortable using Sotradecol and believe it represents the current gold standard for sclerotherapy. We do
not believe that hypertonic saline is of any use except in the rare instance of a patient with tiny spider veins, no large
feeder veins, and has an allergy to Sotradecol.
Michigan Vein Institute uses Sodium Tetradecyl Sulfate for all sclerotherapy procedures. It is the most
effective, safest, least painful, and it is FDA approved.
Dr. Benson Trains At Harvard
Dr. Benson also made a trip to Boston in the summer of 2004 where he completed a preceptorship in EndoVenous
Laser Therapy (EVLT) at Harvard Medical School / Brigham & Womens Hospital. Dr. Benson worked with Dr. Richard
A. Baum, Chief of the Division of Angiography & Interventional Radiology and his associate, Dr. Christoph Binkert.
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In this section, Doctor Benson will respond to selected questions recieved by e-mail that may be of interest
to many of you.
Q.: How does my insurance company decide if they will cover treatment of my veins? -- J. R., Traverse City
A.: Because they vary so greatly, I cannot give you an answer that applies to all insurance carriers. However,
the general rules that most adhere to are as follows:
- You have or had venous ulcers; OR
- You have or had recurrent phlebitis or inflammation; OR
- You have or had significant bleeding from a varicose vein requiring a blood transfusion or more than one episode of bleeding
that was less severe; OR
- You have significant pain or swelling that interferes with your normal activity, or prevents you from doing things you
might otherwise do, or you are unable to complete normal activities unless you endure pain or swelling. The symptoms
do not need to be present all of the time but must be present at least part of the time to qualify. If this category
is the justification you must meet the following criteria:
- You must wear compression stockings for 2 to 6 months (varies by insurance carrier) prior to treatment.
- Some require the stockings to be prescription and 30/40 mmHg type.
- You must try other conservative methods such as leg elevation, walking/exercise, OTC analgesics(Tylenol/Advil).
To expedite treatment, patients need to document on their Patient History form that they have completed these requirements.
If these are not documented on the initial patient history, treatment could be delayed for 2 to 6 months to allow time for
the patient to meet the requirement for a trial period of compression stocking use. While there is no procedure for
verfying that a patient has actually worn the stockings, we cannot and will not alter the history of stocking use once a patient
has told us they have not worn them for the required period. We have no alternative but to postpone treatment long enough
for a patient to wear the stockings for the required period or collect cash at the time of service and not file insurance.
We recommend that patients should contact their insurance carrier prior to their consultation if possible to verify the requirements
and benefits of their plan.
REPEAT: IT IS VERY IMPORTANT THAT YOU DOCUMENT YOUR COMPRESSION STOCKING USE ON YOUR MEDICAL HISTORY FORM
AND VERIFY THAT YOU HAVE WORN THEM FOR THE REQUIRED LENGTH OF TIME.
Q.: The insurance company says they need the codes, what are they? -- C.B., Gaylord
A.: There are 2 types of codes used by the insurance companies, diagnosis codes (ICD-9) and procedure codes
(CPT-4). The diagnosis codes most commonly used are:
- Varicose veins with:
- 454.0 (ulcer & inflammation)
- 454.1 (inflammation)
- 454.2 (ulcer)
- 454.8 (pain or swelling)
- 454.9 (asymptomatic)
- Spider veins 448.1
Green= Usually covered Yellow = Often
covered Red= Usually not covered
Typical procedure codes are:
- 36470 Sclerotherapy - single vein
- 36471 Sclerotherapy - multiple veins
- 36478 Endovenous laser ablation - 1st vein
- 36479 Endovenous laser ablation - 2nd vein same leg
- 76942 Ultrasound guidance for needle placement
- 93970 Duplex Ultrasound - bilateral legs
- 93971 Duplex Ultrasound - single leg or limited
- 93965 Doppler scan or Digital Photoplethysmography (D-PPG)
- 99204 Initial office visit
Most commonly used treatment codes
Diagnostic procedures
When you call to find out about coverage or medical policies, you will need the code number of the treatment and the diagnosis
code that fits your symptoms. Some carriers require pre-determination or a letter of medical necessity. You should
ask if this is needed when you call.
Q.: I have had sclerotherapy in the past (spider veins injected) . It gave me bruises that are still visible
after 3 years. What do you recommend now and will Medicare cover the procedure? I also have a large varicose vein.
---L.D., Standish
A.: The way sclerotherapy has typically been done in the past by non-phlebologists is to used
concentrated salt solution and inject only the spider veins. The result: painful injections, possible scars and poor
results. The key to successful vein treatment whether it is for varicose or spider veins is to identify the "feeder
veins" that lead to the visible veins and cut off the source of reflux before treating the surface veins. This often
involves using duplex ultrasound to map the veins of the leg and guide treatment. Medicare (and most other insurance)
covers the office evaluation and diagnostic ultrasound (also done in the office). Whether Medicare will cover treatment
depends on the diagnosis. Medicare will cover treatment of symptomatic varicose veins. Specifically varicose veins
with pain, swelling, inflammation, bleeding, or ulceration. They will not cover cosmetic treatment in the absence of
symptoms. Medicare also requires patient to try wearing compression stocking prior to sclerotherapy or laser treatment
of varicose veins. At our initial evaluation we give each patient a list of the diagnosis and procedure codes that are
specific to their condition so they can contact their insurance company to check coverage. I
suspect what looks like three-year old bruises may be collections of abnormal veins (matting) and not actually bruises.
Q: Why do my legs ache at the end of the day? -- V.P., Sault Ste. Marie
A: People who spend many hours per day standing or sitting generally have poor venous return from their legs. When
people have visible varicose veins there is an obvious cause for aching legs, but not everyone with venous insufficiency or
aching legs from poor venous flow has huge varicosities. A simple test: Get a pair of support or compression hose (stockings),
preferably 16/20, 20/30, or 30/40 compression (they will be labelled 16/20 (Class 0), 20/30 (Class I), 30/40 (Class II),
etc.). Wear them during the hours when you do your prolonged standing or sitting. If your legs feel better, your
problem may be from poor venous return. An ultrasound examination by a phlebologist can confirm the existence of venous
reflux and recommend treatment.
Note: Some insurance companies require use of 30/40 mmHg (Class II) thigh high stockings as a prerequisite
to other vein treatment. Class II stockings are fairly snug and can be difficult to put on. Correct sizing is
essential to a good fit. You must be measured to get a proper fit. We use Medi USA Class II thigh high stockings
after each vein treatment. Jobst and Sigvaris are acceptable quality. We do not recommend any other
brands at this time.
Q.: How often are you in your Gaylord office? -- F.B, Mt. Pleasant; A.J., Newberry
A.: We adjust our schedule based on need. We currently are in three of our four offices every week. For example:
One week we may split the week between Alpena, Saginaw, and Gaylord. Another week we may divide between Saginaw, Acme
and Alpena.
Q.: I live over 100 miles away. Will you be opening any additional offices? -- M.B.S., Saginaw
Updated Answer: In June of 2007 we opened our new 5000 square
foot facility at 5703 Bay Road in Saginaw. Now residents of Bay City, Saginaw, Midland, Flint, and the surrounding area have
convenient access to Michigan's leading vein specialists. We are currently training another physician to increase our capacity
in Saginaw and other locations.
While we do not have an exact timetable, we are continuing to investigate new office locations. Locations being
considered are Petoskey, Cadillac, Mt. Pleasant, and Sault Ste. Marie as well as metropolitan clinics in southern Michigan.
As our current clinics in Traverse City, Saginaw, Alpena, and Gaylord are operating close to the maximum capacity for
our existing personnel, hiring and training of additional physicians, nurses and vascular ultrasonographers will be needed.
We are currently looking for physicians who would be interested in training with Dr. Benson to become phlebologists and staff
our new locations.
Additionally, for patients having endovenous laser ablation done on consecutive days (i.e. left leg on Thursday and right
leg on Friday), we have set up a program to cover your motel room for the night in between the procedures if you live over
100 miles away. (We get to pick the motel.)
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