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:  http://csvi-ms.net/en/content/publications-venous-multiple-sclerosis


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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