Mountain State Medical Policy Bulletin |
Section: | Surgery |
Number: | S-55 |
Topic: | Surgical Treatment of Varicose Veins |
Effective Date: | April 16, 2007 |
Issued Date: | September 10, 2007 |
Date Last Reviewed: | 08/2007 |
Indications and Limitations of Coverage
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). Surgical treatment of varicose veins on the contralateral extremity is eligible only if that leg is also symptomatic. 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)
Ambulatory Phlebectomy (e.g., Stab Phlebectomy)(procedure codes 37765, 37766, 37799) Description: When performing fewer than ten (10) incisions, report 37799. Transilluminated Powered Phlebectomy (procedure code 37785) Description: 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:
Failed conservative measures must include at least eight (8) weeks of:
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: 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.
Policy Guidelines: The following are patient selection criteria for VNUS Closure and EVLT:
The patient has significant medical problems related to varicosities as evidenced by at least one of the following:
Failed conservative treatment must include a trial of at least eight (8) weeks of ALL of the following:
Contraindications (when EVLT or VNUS procedure is NOT covered):
* 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: Sclerotherapy is eligible for payment for those patients who meet the following criteria: Symptomatic varicose veins:
All of the following treatments must have failed (for at least 8 weeks) prior to sclerotherapy:
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):
This procedure should be reported under codes 36470 for one vein or 36471 for multiple veins on the same leg. Code 36471 should be reported only once per leg. When sclerotherapy is performed on both legs at the same surgical session, services will be processed in accordance with the bilateral multiple surgery guidelines on Medical Policy Bulletin S-100. 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. The following services are not eligible for reimbursement: Echosclerotherapy (procedure code S2202) Description: Non-Invasive Laser Treatment (procedure code 37799) 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) Description: Treatment of Spider Veins
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. |
|
36468 | 36469 | 36470 | 36471 | 36475 | 36476 |
36478 | 36479 | 37500 | 37700 | 37718 | 37722 |
37735 | 37760 | 37765 | 37766 | 37780 | 37785 |
37799 | S2202 |
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program. |
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 Optimal Pulse Durations for the Treatment of Leg Telangiectasias with a Neodymium YAG laser, Lasers in Surgery and Medicine, Volume 38, February 2006 A Side-by-Side Prospective Study of Intense Pulsed Light and Nd: YAG Laser Treatment for Vascular Lesions, Annals of Plastic Surgery, Volume 56, Number 2, February 2006 The 800-nm diode laser in the treatment of leg veins: Assessment at 6 months, Journal of the American Academy of Dermatology, Volume 54, Number 2, February 2006 Laser Treatment of Vascular Lesions, Dermatologic Clinics, Volume 23; 2005 Laser Treatment of Leg Veins, Seminars in Cutaneous Medicine and Surgery, Volume 24; 2005 |