As featured in the December issue of MedForum magazine.
The 1 November 2021 changes to MBS descriptors if not properly understood may deny worthy patients’ treatment.
In summary, MBS rebates apply if patients have “significant signs or symptoms attributable to venous reflux (including one or more) of:
Ache, pain, tightness, skin irritation, heaviness, muscle cramps, limb swelling, discoloration or any other sign or symptom attributable to venous reflux.”
The admixture of signs/symptoms together is rather confusing, but I will attempt to clarify.
Symptoms are subjective and must be interpreted in a holistic context. Symptoms are not confirmed by the presence of large veins or reflux on Doppler, nor denied by their absence. Restless Leg Syndrome (RLS) in association with reflux would qualify, vein-related emotional distress due to cosmesis probably not!
Regarding signs, the CEAP classification below is a useful guide but proper application requires an experienced and trained eye as relevant findings may be easily missed.
C3 (oedema) may be quite subtle and C4 skin changes are frequently undiagnosed/misdiagnosed by GP’s. Corona Phlebectasia C4c (fig 2) is often mistaken for C1 rather than C4 disease and usually indicates significant saphenous reflux with increased risk of progression to venous ulcers.
Treatment is indicated in those with C3-C6 disease to prevent progression.
C2 disease will qualify for MBS rebates when associated with significant symptoms and C1 disease will now qualify if non-cosmetic and associated with documented proximal saphenous reflux of > 0.5 seconds.
Varicose veins are commonly symptomatic (50% having RLS in our cohort) and even if not, patients are often willing to pay out-of-pocket costs for NSVT.
Varicose veins are often not simply a cosmetic issue, regardless of the associated aesthetics.
Unfortunately, patients commonly advise “my GP said they are just cosmetic”, despite advanced signs of venous disease including pigmentation and Lipodermatosclerosis.
Patients requesting treatment for their varicose veins deserve to be taken seriously and should be referred for NSVT to an appropriate practitioner, as per the MBS criteria below.
“It is recommended that the medical practitioner performing the above procedures has successfully completed a substantial course of study and training in duplex ultrasound and the management of venous disease, which has been endorsed by their relevant professional organisation”.
Just as the title “Cosmetic Surgeon” does not guarantee a surgically trained practitioner, the names “Surgeon”, “Vascular Surgeon”, “Radiologist”, “Interventional Radiologist” or even “Phlebologist”, do not guarantee someone who is able to deliver optimal NSVT.
Private medicine remains a situation of “buyer beware” and whilst it is important to understand a practitioner’s background and training, more important is the relevant experience, case load, and outcomes delivered. Paper qualifications alone do not denote satisfactory training or outcomes with NSVT, especially given their recent introduction and rapidly evolving nature which require a high degree of technical skill with Duplex ultrasound and ultrasound-guided procedures.
In summary, patients should not be denied referral if they wish to have their varicose veins treated but referring doctors should understand the limitations of a practitioner’s title per se, and advise patients that if their concerns are simply cosmetic, MBS rebates likely do not apply but treatment is still available if they are willing/able to pay for it.