Varicose veins are elongated, dilated, tortuous superficial veins that have become incompetent, permitting reversed flow in the dependent position. Symptoms associated with varicose veins include aching, fatigue, or heat that is relieved by elevating the leg or by wearing compression hose.

The treatment of varicose veins of the lower extremities is considered medically necessary when the following criteria are met prior to the decision for treatment:

1. A minimum 3-month trial of conservative therapy with graduated elasticized compression stockings has failed or was not feasible.
   
   
2. The patient is symptomatic and the varicosities result in any one or more of the following in spite of conservative therapy:
   
   
   1. Persistent symptoms interfering with activities of daily living such as aching, cramping, burning, pain, itching and/or swelling during activity or after prolonged standing.
   2. Significant, recurrent superficial phlebitis.
   3. Hemorrhage from ruptured varix.
   4. Non-healing skin ulceration of the lower extremity.
      
      
3. Duplex studies of the venous system are performed by an accredited vascular technician that fully defines the anatomy, size, and tortuosity of the greater and lesser saphenous vein, superficial venous segments and perforators. Studies must demonstrate the following criteria:
   
   
   1. Absence of deep venous thrombosis, and;
   2. Greater saphenous vein valvular incompetence/reflux that correlates with the patient’s symptoms.
      
      
4. In addition, the following conditions apply to specific individual procedures.

   Injection/Compression Sclerotherapy
   
   

   1. No saphenofemoral insufficiency, incompetency, or occlusion of the deep venous system; and
   2. Vessel diameter should be at least 3 millimeters in size.

   Surgical Ligation or Stripping
   
   

   1. May be covered as part of a combination procedure with sclerotherapy;
   2. Number of veins and their locations should be documented.

   Endoluminal Radiofrequency Ablation (ERFA) or Laser Ablation
   
   

   1. Patient’s anatomy is amenable to laser or radiofrequency catheter;
   2. Non-aneurismal saphenous vein(s);
   3. Absence of vein tortuosity that would impair catheter advancement.

   Ambulatory or Stab Phlebectomy
   
   

   1. Use of 2mm stab incisions to remove vein via crochet type hook;
   2. May be covered only when the patient displays symptoms and functional problems attributable only to the secondary, smaller vessels;
   3. Not covered on the same date of service as another vein procedure, such as ERFA.

   Subfascial Endoscopic Perforator Surgery (SEPS)
   
   

   1. Must have symptoms of perforator incompetence;
   2. Must have a venous stasis ulcer in which a history of conservative measures failed.

When reported for non-symptomatic varicose veins or other non-covered indications, these surgical options are considered cosmetic. A provider can bill the member for these non-covered services.

Limitations

Noncompressive sclerotherapy implies injection of the sclerosant into veins when the patient is upright and the veins are full. Technically, this is thrombotic therapy, not sclerotherapy. This method has not been shown effective in producing long-term obliteration of the incompetent veins and is not covered.

The treatment of spider veins or superficial telangiectasis by any technique is considered cosmetic, and therefore not covered, unless there is associated significant and persistent bleeding.

Laser treatment of superficial varicosities or spider veins is considered cosmetic and is not covered.

Ultrasound-monitored or duplex-guided techniques for sclerotherapy (S2202) will not be covered when used in conjunction with injection sclerotherapy techniques. The provider cannot bill the member for the non-covered service.

Pre-operative venous studies will be covered when initially performed to determine the extent of venous valvular incompetence.

Additional reimbursement is not available for these or other radiologically guided or monitoring techniques when performed solely to guide the needle or introduce the sclerosant into the varicose vein.

Symptomatic improvement is the primary goal and indicator of a satisfactory outcome. Documentation of recanalization or failure of vein closure without recurrent signs and symptoms does not necessarily indicate a need for additional treatments.

Services performed for excessive frequency are not medically necessary. Frequency is considered excessive when services are performed more frequently than generally accepted by peers and the reason for additional services is not justified by documentation.

Documentation Requirements

The patient's medical record must document the medical necessity of services performed for each date of service submitted on a claim.

For all varicose vein treatment modalities discussed in this policy, the patient’s operative report, medical treatment history, and progress notes documenting patient compliance with prescribed conservative treatment must clearly indicate that all initial and procedural coverage criteria are met as outlined under the Indications section of this policy.

Medical record documentation must specifically state the vessel(s) and perforator(s) treated for each procedure, as well as the vessel diameter. If additional procedures are performed on the same vessel(s) at a future date, documentation must show a recurrence of signs and symptoms, which are specifically caused by that vessel. Otherwise, the procedure will be considered cosmetic.

All documentation must be available upon request.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

The following coding information is specific to the Sclerotherapy LCD.

If both legs are injected, the following coding conventions must be used:

• One vein on the left; two veins on the right: Use code 36470 with modifier LT and code 36471 with modifier RT;
  
  
• One vein on each leg: Use code 36470 with modifier RT and CPT code 36470 with modifier LT;
  
  
• Two veins on the right; three on the left: Use code 36471 with HCPCS modifier RT and code 36471 with modifier LT;
  
  
• Submit the claim with a quantity of one unit per code for each of the above examples.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Use of these codes does not guarantee reimbursement. The patient’s medical record must document that the coverage criteria in this policy have been met.