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

The patient has significant medical problems related to varicosities as evidenced 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 at least eight (8) weeks of all of the following:

• Routine use of Nonsteriodal Anti-inflammatory Drugs (NSAIDS), unless contraindicated, and
• Compression hose providing at least 30mm Hg pressure, and
• Leg elevation above heart level as often as possible, and
• Walking/exercising regularly as often as possible

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.

Transilluminated powered phlebectomy is eligible for reimbursement when the following symptoms and conservative measures are met:

The patient has significant medical problems related to varicosities as evidenced 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 measures must include at least eight (8) weeks of all of the following:

• Routine use of Nonsteroidal Anti-inflammatory Drugs (NSAIDS), unless contraindicated and
• Compression hose providing at least 30mm Hg pressure
• Leg elevation above heart level as often as possible
• Walking/exercising regularly as often as possible

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 as an alternative to ligation and stripping when the symptoms and conservative measures noted below are met. Procedure codes include the imaging guidance. Separate payment will not be made for imaging guidance reported with the above noted procedure codes.

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.

VNUS Closure and EVLT are eligible for payment for those patients who meet the following criteria:

• Greater saphenous vein reflux and saphenofemoral junction incompetence, or lesser sapehnous vein reflux and saphenopopliteal junction incompetence, or accessory vein incompetence as documented by Doppler ultrasound, and
• Non-aneurysmal saphenous veins, and
• Absence of vein tortuosity, which would impede catheter advancement, and
• Venous insufficiency meets clinical classification of 4, 5, or 6 as indicated in the table attachment titled "Clinical Classification of Chronic Venous Insufficiency"

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:

• Routine use of Nonsteroidal Anti-inflammatory Drugs (NSAIDS), unless contraindicated, and
• Compression hose providing at least 30mm Hg pressure, and
• Leg elevation above heart level as often as possible, and
• Walking/exercising regularly as often as possible

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
• Anticoagulant therapy
• Inability to tolerate a compression bandage/stocking

* 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.

Visual Sclerotherapy (procedure codes 36470 and 36471)

Visual 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
• Photographic evidence of varicosities that are demonstrable (bulging) above the surface of the skin, and
• 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 at elast eight (8) weeks of all of the following:

• Routine use of Nonseteroidal Anti-inflammatory Drugs (NSAIDS), unless contraindicated, and
• Compression hose of providing at least 30mm Hg pressure, and
• Leg elevation above heart level as often as possible, and
• Walking/exercising regularly as often as possible

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

Contraindications (when visual 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
• Anticoagulant therapy, or
• Inability to tolerate a compression bandage/stocking

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 visual 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: Visual 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 visual sclerotherapy may be necessary during the routine surgical postoperative period to achieve a better and more complete surgical result. As such, visual 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.

Echosclerotherapy (procedure code S2202)
Symptomatic varicose veins not visible to the naked eye can be treated by injection guided by ultrasonograhpy. The combined procedure is called echosclerotherapy. During echosclerotherapy, duplex ultrasound is used to guide the injections and enhance the precision of the therapy. Echosclerotherapy is also called aimed sclerotherapy, duplex sclerotherapy, or sonographic sclerotherapy.

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

Symptomatic varicose veins:

• Varicosities are at least 5 millimeters in size, and
• Photographic evidence of varicosities that are demonstrable (bulging) above the surface of the skin, and
• 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 at least eight (8) weeks of the all following:

• Routine use of Nonseteroidal Anti-inflammatory Drugs (NSAIDS), unless contraindicated, and
• Compression hose of providing at least 30mm Hg pressure, and
• Leg elevation above heart level as often as possible, and
• Walking/exercising regularly as often as possible

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

Contraindications (when visual 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
• Anticoagulant therapy, or
• Inability to tolerate a compression bandage/stocking

Echosclerotherapy should be reported under code S2202 which includes the injection and the ultrasound. Separate payment will not be made for the ultrasound guidance. If billed separately, the ultrasound should be denied as not covered. A participating, preferred, or network provider cannot bill the member for the denied service.

Subfascial Endoscopic Perforator Surgery (SEPS - procedure code 37500)
Subfascial endoscopic perforator surgery (SEPS) is covered when all of the following medical necessity criteria are met:

• There is documented Doppler evaluation and/or Duplex ultrasonography of the incompetent perforator vein, and it is located on medial aspect of the calf being treated.
• There is documented failure of conservative management (e.g., leg elevation, compression therapy) for 6 months.
• There is documentation of at least one of the following - venous stasis, dermatitis/ulceration, chronic venous insufficiency.

If reported for criteria other than listed above, it is considered not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

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).

The following services are not eligible for reimbursement:

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.

Treatment of Spider Veins
Any method of treatment for reticular veins and/or superficial telangiectases, including laser, 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.

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.