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: Angela Williams

Date of Birth: 12/17/63
Date: 7/4/23
RE: DETERMINATION OF MEDICAL NECESSITY FOR CHRONIC VENOUS
INSUFFICIENCY REQUIRING SCLEROTHERAPY

Dear Sir/Madam,
The purpose of this letter is to certify that the above named patient suffers from varicose
veins with pain and venous insufficiency (ICD-10 code I83.812 and I87.2). This
condition requires medical attention and treatment.
The required treatment is as follows: Ultrasound guided sclerotherapy of symptomatic
varicose veins. Compression stockings are also required for a short time period 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 symptomatic bilateral lower extremity varicose
veins, pain, swelling, and pigmentation. She has not had improvement with
compression stockings and complains of difficulties with activities of daily living. She
has not had any sclerotherapy treatments to the left lower extremity in the past 12
months.

The patient needs certification of medical necessity for the following procedures:
Ultrasound guided sclerotherapy of the left lower extremity severely incompetent
varicose veins associated with pain, edema, and skin pigmentation (CPT 36471-LT and
76942)

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.