Oops, too many lines . will break it into several sections . 


From: Franklin W. West [mailto:[log in to unmask]] 
Sent: Thursday, January 07, 2010 8:52 AM
To: 'UVM Flownet'
Subject: RE: Chronic cerebrospinal venous insufficiency (CCVI)




I am not certain that I agree with your conclusion that intracranial
evaluation is 'overkill'.  While I certainly understand the current therapy
being investigated is extracranial, I suspect that limiting interrogation to
the extracranial system may miss a fundamental point - i.e., the theorized
problem that might necessitate therapy is intracranial and hemodynamic.
Thus, if only the extracranial system is evaluated, and assuming the
findings are then used for intervention, it would seem entirely possible
that interventions would occur in some potentially significant number of
patients that, in fact, have no intracranial hemodynamic abnormality - thus
likely making any intervention pointless.  


Certainly, I believe we need to recognize that duplex scanning for CCSVI is
NOT beyond the investigational phase and is thus, by definition, NOT
medically necessary.  Further we should be aware that MS patients, as a
group, represent a vulnerable population and, given this is clearly
investigational, I can think of no ethical reason that patients would be
charged for any of these procedures.  The benefit at this point is to us in
the investigational phase, not to the MS patients.  [this ignores that fact
that no CPT or HCPCS codes exists specific to this procedure]


Being 'old as dirt' (at least to some), I do recall what I think might be an
analogy - i.e., ECA-ICA bypass grafting.  When I first came across this
procedure (at least locally), it was being performed on a very select (read
'small') group of symptomatic patients with demonstrated intracranial
hemodynamic compromise with concomitant ICA occlusions, larger STAs, etc.
However, with time, this procedure was applied to a more inclusive group of
patients (seemed to me that it was almost anyone with an ICA occlusion and
any symptoms that might remotely be related) with, IMHO, the result being
that it lost its initially documented value - with the eventual result that
it essentially fell into disrepute.  


The best resource page I've come across is:


All the best for a happy and healthy new year J


Franklin W. West


Director, Professional Services

Pacific Vascular Inc.

11714 North Creek Parkway North

Suite 100

Bothell, WA   98011-8250

425.398.7774 (office)

425.486.8976 (fax)

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