When conservative treatments fail to provide relief from symptomatic varicosities, the following surgical options are eligible for reimbursement when reported for symptomatic varicose veins (454.0-454.8). When reported for non-symptomatic varicose veins (454.9) these surgical options are considered cosmetic. Participating, preferred, or network providers can bill the member for these denied services.

Ligation and Stripping (procedure codes 37700-37785)
Ligation and stripping procedures are beneficial in the treatment of symptomatic varicose veins and, as such, are covered surgical services. 

Ambulatory Phlebectomy (e.g., Stab Phlebectomy)(procedure codes 37765, 37766, 37799)
Ambulatory phlebectomy is an eligible service.

Description:
Ambulatory phlebectomy is a minimally invasive procedure performed as an alternative to ligation and stripping of veins that are too large for successful sclerotherapy. Prior to the procedure, the veins are located using a Doppler ultrasound. After the vein is marked, it is removed through pinhole incisions made along the length of the vein.

When performing fewer than ten (10) incisions, report 37799.

Transilluminated Powered Phlebectomy (procedure code 37785)
Transilluminated powered phlebectomy (TPPS) is considered an eligible alternative treatment of varicose veins.

Description:
Transilluminated powered phlebectomy (e.g., TriVex System) is a minimally invasive procedure in which an endoscopic illuminator is inserted into the vein to allow visualization of the varicose vein clusters. The veins are then ablated using a vein resector. During destruction of the veins, the debris is removed from the wound using suction.

Ligation and stripping, ambulatory phlebectomy (stab phlebectomy) and transilluminated powered phlebectomy are eligible for reimbursement when the following symptoms and conservative measures are met: 

The patient has significant medical problems related to varicosities as evidenced by a photograph and at least one of the following:

• Persistent leg aching, burning, cramping, swelling or heaviness, or
• Superficial Thrombophlebitis, or
• Bleeding from a varix

Failed conservative measures must include at least eight (8) weeks of:

• Nonsteroidal Anti-inflammatory Drugs (NSAIDS), unless contraindicated and
• Compression hose providing at least 30mm Hg pressure

Endovenous Radiofrequency Obliteration (VNUS) of Incompetent Veins (procedure codes 36475, 36476) or Laser Obliteration (EVLT) of Incompetent Veins (procedure codes 36478, 36479)

VNUS Closure or EVLT is eligible for reimbursement for documented saphenofemoral reflux as an alternative to ligation and stripping when the following symptoms and conservative measures are met.  Procedure codes include the imaging guidance.  Separate payment will not be made for imaging guidance reported with the above noted procedure codes. 

Description:
Endovenous radiofrequency (e.g., the VNUS Closure procedure) is a minimally invasive treatment used as an alternative to saphenous vein ligation and stripping in patients with symptomatic venous insufficiency of the lower extremities (e.g., varicose veins). It involves the use of a catheter temporarily inserted into the patient’s saphenous vein. This procedure utilizes radiofrequency energy at the catheter tip to heat the vein to approximately 85 degrees, which results in contraction of the vein. As the catheter is slowly withdrawn from the vein, the heat causes the vein to collapse and occlude thus terminating the reflux that causes the patient’s symptoms.

Laser obliteration of incompetent veins is also a minimally invasive procedure that is performed in a fashion similar to endovenous radiofrequency obliteration. A bare tipped laser fiber is introduced into the saphenous vein under ultrasonic guidance. The laser is activated and slowly removed along the course of the saphenous vein.

The catheter insertion is part of the overall procedure and should not be billed separately. If billed separately (e.g., 36010, 36011), the catheter insertion should be denied as not covered. A participating, preferred, or network provider cannot bill the member for the denied service.

Laser obliteration with ultrasonic guidance is a covered service. Procedure codes 36478 and 36479 include imaging guidance. Separate payment will not be made for imaging guidance billed with procedure codes 36478 and/or 36479.

NOTE:

Procedure codes 17106-17108 should not be used to report laser destruction of varicose veins.

Policy Guidelines:

The following are patient selection criteria for VNUS Closure and EVLT:

• Greater saphenous vein reflux and saphenofemoral junction incompetence as documented by Doppler ultrasound, and
• Non-aneurysmal saphenous veins, and 
• Absence of vein tortuosity, which would impede catheter advancement, and
• Photographs, and
• Maximum saphenous vein diameter of 12 mm (VNUS procedure only)

The patient has significant medical problems related to varicosities as evidenced by at least one of the following:

• Severe, persistent leg aching, burning, itching, cramping and/or swelling interfering with activities of daily living, or
• Intractable ulceration secondary to stasis dermatitis, or
• Recurrent hemorrhage from a superficial varicosity, or
• A single hemorrhage from a ruptured superficial varicosity if a blood transfusion is required, or
• Recurrent superficial thrombophlebitis.

Failed conservative treatment must include a trial of at least eight (8) weeks of ALL of the following:

• Analgesics (NSAIDS), and
• Leg elevation above heart level, and  
• Compression hose providing at least 30mm Hg pressure

Contraindications (when EVLT or VNUS procedure is NOT covered):

• Deep vein thrombosis or a non-patent deep venous system, or
• Within six (6) months of pregnancy, or
• Presence of lymphedema, or
• Arterial insufficiency, or
• Diabetes, or
• Anticoagulant therapy

* Requests for EVLT or VNUS Closure for patients with a past history of greater saphenous vein surgical intervention of requested extremity should be referred to the Medical Director.

Sclerotherapy (procedure codes 36470 and 36471)

Description:
The injection of sclerosing solution into varicose leg veins irritates the lining of the vein causing it to close. The blood flow is then diverted through healthier veins.

Sclerotherapy is eligible for payment for those patients who meet the following criteria: 

Symptomatic varicose veins:

• Varicosities are at least 5 millimeters in size, and
• Varicosities are demonstrable (bulging) above the surface of the skin, and
• Photographic evidence, and
  • Symptoms may include swelling, aching, cramping, heaviness of the lower extremities, or
  • Recurrence of superficial thrombophlebitis, or
  • Recurrent bleeding from a varix, or
  • A single hemorrhage from a ruptured superficial varicosity if a blood transfusion is required

All of the following treatments must have failed (for at least 8 weeks) prior to sclerotherapy:

• Analgesics (NSAIDS), and
• Leg elevation above heart level, and
• Compression hose providing at least 30mm Hg pressure

Doppler ultrasonographic documentation of reflux of the saphenofemoral junction or reflux isolated to the perforator veins of the upper thigh.

Contraindications (when sclerotherapy is NOT covered):

• Deep vein thrombosis or a non-patent deep venous system, or
• Within six (6) months of pregnancy, or
• Presence of lymphedema, or
• Arterial insufficiency, or
• Diabetes, or
• Anticoagulant therapy, or
• Inability to tolerate a compression bandage/stocking

NOTE:  Sclerotherapy treatment will be limited to six (6) sessions, after which time a re-review will be required for determination of medical necessity for additional treatment sessions. 

In some cases, limited sclerotherapy may be necessary during the routine surgical postoperative period to achieve a better and more complete surgical result. As such, sclerotherapy performed by the surgeon, his associate or, the assistant surgeon during the postoperative period following vein ligation and stripping procedures is part of the global surgical allowance. A participating, preferred, or network provider cannot bill the member separately for these services.

Claims for multiple injections should be processed in accordance with the multiple surgery guidelines on Medical Policy Bulletin S-100. All secondary injections should be priced at 50% of the allowance.

The following services are not eligible for reimbursement:

Echosclerotherapy (procedure code S2202)
Echosclerotherapy is beyond the experimental/investigational stage but it is not generally accepted by the medical community as clinically useful as treatment for varicose veins. Therefore, it is not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

Description:
During echosclerotherapy (S2202), duplex ultrasound is used to guide the injections and enhance the precision of saphenous vein sclerotherapy. However, there are no proven indications that echosclerotherapy provides any advantage over and above conventional methods of treatment such as sclerotherapy or ligation and stripping.

Non-Invasive Laser Treatment (procedure code 37799)
Date Last Reviewed - 08/2005
Non-invasive laser treatment of veins is not covered. This method of treatment, e.g., Vasculite Nd Yag, intense pulsed light (IPL), performed for small superficial, reticular, and telangiectatic veins is cosmetic. A participating, preferred, or network provider can bill the member for this denied service.

In addition, this method of treatment for larger veins is considered investigational and, therefore, is not covered. Scientific evidence does not demonstrate the effectiveness of this treatment. A participating, preferred, or network provider can bill the member for the denied service.

Subfascial Endoscopic Perforator Surgery (SEPS - procedure code 37500)
Date Last Reviewed - 1/2005
Subfascial endoscopic perforator surgery (SEPS) is considered investigational. There is inadequate evidence to permit scientific conclusions about the efficacy of SEPS, either in terms of promoting healing of existing venous ulcers, or preventing their recurrence in comparison to medical therapy or to surgical treatment of the superficial venous system alone. Participating, preferred, and network providers can bill the member for the denied service.

Description:
Subfascial endoscopic perforator surgery (SEPS) is a minimally invasive procedure designed to interrupt incompetent perforator veins. The perforator veins are those veins that connect the deep venous system (i.e., the femoral and popliteal veins) with the superficial venous system (i.e., the greater and lesser saphenous veins).

Treatment of Spider Veins
Any method of treatment for reticular veins and/or superficial telangiectases, including laser, is not covered. Treatment of these superficial veins is primarily cosmetic in nature.

• The injection of sclerosing solution into telangiectasia such as spider veins, hemangiomata and angiomata should be reported with codes 36468 and 36469).
• Laser destruction of reticular veins and/or telangiectasis (e.g., VascuLite) should be reported with code 37799 (Unlisted procedure, vascular surgery).

NOTE:  Procedure codes 17106-17108 should not be used to report the treatment of reticular veins and/or spider veins.

Participating, preferred, or network providers can bill the member for services denied as cosmetic.

See Medical Policy Bulletin S-28 for information regarding Cosmetic Surgery.

Description

Varicose veins, which usually occur in the lower extremities, are dilated superficial veins whose valves have become incompetent, permitting reversed blood flow when the extremities are in the dependent position. The vascular dilatation results from increased pressure within the veins, as often occurs if the individual stands for long periods of time. Genetics, pregnancy and obesity contribute to the development of varicose veins.

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.

Injection of sclerosing solution into superficial telangiectases is done primarily for cosmetic purposes and should be processed in accordance with the guidelines for cosmetic and reconstructive procedures (Medical Policy Bulletin S-28)

PRN References

10/1993, Sclerotherapy of Varicose Veins, coverage for
05/1994, Sclerotherapy, postoperative, reimbursement for
08/1998, Echosclerotherapy
12/2000, Endovenous radiofrequency obliteration of the greater saphenous vein considered investigational
12/2001, How to report laser destruction of varicosities
12/2002, Endovenous radiofrequency obliteration of the greater saphenous vein eligible for reimbursement
06/2003, Blue Shield pays for specific treatments of symptomatic varicose veins, treatment of spider veins not covered
12/2003, Non-invasive laser treatment of vein not covered
04/2004, How to report radiofrequency obliteration of the greater saphenous vein
04/2005, Subfascial endoscopic perforator surgery (SEPS) considered investigational
04/2006, How to report stab phlebectomies

Closure of the Greater Saphenous Vein with Endoluminal Radiofrequency Thermal Heating of the Vein Wall in Combination with Ambulatory Phlebectomy: Preliminary 6-Month Follow-up, Dermatologic Surgery, Volume 26, Issue 5, May 2000

Treatment of Primary Venous Insufficiency by Endovenous Saphenous Vein Obliteration, Vascular Surgery, Volume 34, No. 3, May/June 2000

Endovenous Techniques for Elimination of Saphenous Reflux: A Valuable Treatment Modality, Dermatologic Surgery, Volume 27, No. 10, October 2001

Closure of the Greater Saphenous Vein with Endoluminal Radiofrequency Thermal Heating of the Vein Wall in Combination with Ambulatory Phlebectomy: 50 Patients with More than 6-Month Follow-up, Dermatologic Surgery, Volume 28, No. 1, January 2002

Controlled Radiofrequency Endovenous Occlusion Using a Unique Radiofrequency Catheter Under Duplex Guidance to Eliminate Saphenous Varicose Vein Reflux: A 2-Year Follow-up, Dermatologic Surgery, Volume 28, No. 1, January 2002

Endovenous Laser Treatment of the Incompetent Greater Saphenous Vein, Journal of Vascular Interventional Radiology, Volume 12, No. 10, October 2001

Endovenous Laser: A New Minimally Invasive Method of Treatment for Varicose Veins – Preliminary Observations Using an 810 nm Diode Laser, Dermatologic Surgery, Volume 27, 2001

Powered Phlebectomy (TriVex) in Treatment of Varicose Veins, Annals of Vascular Surgery, 2002

MPRM 7.01.90