General Criteria (1-6) for coverage of symptomatic varicose veins

All of the following general criteria must be met for any and all varicose vein treatment to be considered for coverage. All criteria needs to be documented in the patient's medical record and available upon request:

1. Treatment for symptomatic varicose veins is eligible for reimbursement when the patient presents with evidence of at least one of the following:
   • Significant documented limitations of activities of daily living caused by persistent severe lower extremity symptoms attributable to the varicose vein(s)(e.g., pain, cramping, burning, itching, and swelling) that fail to respond to conventional treatment.
   • Ulceration from venous stasis where incompetent varices are a significant contributing factor and that fail to respond to conservative treatment;
   • Hemorrhage or recurrent bleeding episodes from  ruptured superficial varicosity;
   • Significant recurrent superficial thrombophlebitis that fails to respond to conservative treatment
     
     
2. The clinical documentation must indicate at least 3 months of failed conservative treatment and include all of the following:
   • Compression hose providing at least 30 mm Hg pressure;
   • Leg elevation above heart level as often as possible; and,
   • Walking/exercising regularly as often as possible.
     
     
3. Any incompetence/reflux in the superficial system veins (e.g., long and short saphenous veins and saphenous tributaries) must be documented by venous studies.
   
   
4. Photographs are required on any affected areas of the leg, e.g., protruding varicose veins, and must be consistent with the submitted clinical description. A measuring device (ruler) must be included in the picture.
   
   
5. Treatment sessions
   • Requests for coverage of initial sessions are as follows: a bilateral session, or one initial operative session for each leg
   • After the clinical outcome of prior treatment(s) has been established and documented, requests for additional operative sessions one session at a time will be considered. Each additional request must meet all coverage criteria. All documentation must be maintained in the patient's medical record and available upon request.
   • Each treatment session should address as much abnormality as is appropriate and reasonable, and may include more than one modality.
     
     
6. Imaging
   • A Doppler ultrasound or duplex study performed no more than 12 months prior to the  procedure  is medically necessary prior to the treatment session(s) to map the anatomy of  the venous system and evaluate for deep and superficial venous incompetence, when the    other general criteria (1-5) outlining when treatment for symptomatic varicose veins is  eligible for reimbursement, are met. The Doppler ultrasound or duplex must confirm  incompetence/reflux and must document vein size ≥ 5mm in diameter in  the vein to be  treated. These studies must demonstrate both of the following:
     • Absence of deep venous thrombosis
     • Greater and/or lesser saphenous vein valvular incompetence/reflux that correlates with the individual's symptoms
   • Intraoperative ultrasound guidance
     • Because ultrasound-monitored or duplex-guided techniques for sclerotherapy of varicose veins (echosclerotherapy) have not been to shown to definitively increase the effectiveness or safety of this procedure, echosclerotherapy is considered not medically necessary.
   • Follow-up venous studies or ultrasound performed within six months following the most recent ipsilateral treatment, in the absence of complications, are considered not medically necessary, including but not limited to routine confirmation studies following endovenous ablation.
   • Follow-up venous studies or ultrasound performed six months or longer following the most recent ipsilateral treatment may be medically necessary when the other general criteria (1-5) above outlining when treatment for symptomatic varicose veins is eligible for reimbursement are met.

When conservative treatments fail to provide relief from symptomatic varicosities and the above general criteria requirements (1-6) are met, the following surgical options are eligible for reimbursement when reported for symptomatic varicose veins. However, in addition to the general criteria (1-6), specific requirements for each procedure must also be met and documented in the patient’s medical record.

• Ligation/stripping and phlebectomy (i.e., stab, hook, transilluminated powered)(37700-37761, 37780-37785, 37765, 37766, 37799)
• Endovenous ablation (36475, 36476, 36478, 36479)
• Endomechanical Ablation (37799)
• Sclerotherapy (36470 and 36471)
• Subfascial Endoscopic Perforator Surgery(SEPS)(37500)

When reported for conditions other than symptomatic varicose veins, these surgical options are considered cosmetic, and therefore, non-covered. This includes the diagnosis of non-symptomatic varicose veins. A participating, preferred or network provider can bill the member for the non-covered service.
 
Surgical treatment of varicose veins on the contralateral extremity is eligible only if that leg is also symptomatic.

Ligation/stripping and phlebectomy (i.e., stab, hook, transilluminated powered)(37700-37761, 37780-37785, 37765, 37766, and 37799) 
Ligation/stripping and phlebectomy of incompetent superficial system veins (including the long and short saphenous veins and saphenous tributaries including accessory saphenous veins), and varicose veins ≥ 5 mm in diameter may be considered medically necessary when both of the following criteria are met:

1. Related incompetent  superficial veins proximal to the incompetent vein to be treated either have been or are being treated concurrently
2. All of the general criteria (1-6) above outlining when treatment for symptomatic varicose veins is eligible for reimbursement are met.

• Ambulatory phlebectomy services, procedures codes 37765 and 37766, are reported based on the number of incisions performed on each extremity. When fewer than 10 incisions are required, report code 37799.
• Procedure code 37785 includes the ligation, division, and/or excision of one or more varicose vein clusters and should only be reported once per extremity. Report code 37785 with modifier RT, LT, or 50 as appropriate.
• Ligation of perforator veins, code 37761, includes ultrasound guidance. 

Endovenous ablation (36475, 36476, 36478, 36479) and Endomechanical Ablation (37799)
Endovenous radiofrequency or laser ablation and endomechanical ablation of incompetent greater or lesser saphenous veins may be considered medically necessary when the all of the general criteria (1-6) above, are met.

Endovenous ablation and endomechanical ablation is considered cosmetic, and therefore, non-covered for  all of the following:

1. Cryoablation of any vein
2. Radiofrequency or laser ablation and endomechanical ablation of varicose veins other than the greater or lesser saphenous veins, including but not limited to the following:
   1. accessory saphenous veins
   2. branch tributaries
   3. perforator veins
3. Ablation of saphenous or other veins for treatment of all of the following:
   1. pelvic congestion syndrome
   2. vulvar varices
   3. scrotal varices (varicocele)

One session of endovenous ablation therapy or endomechanical ablation for the greater saphenous vein of one or both legs and one session for the lesser saphanous vein of one or both legs for a total of two sessions is considered medically necessary. Each system should require only one treatment session. (A treatment session may include treatment of multiple veins in one or both legs during a single visit.) Repeat sessions of endovenous catheter ablation or endomechanical ablation or stripping/division/ligation are considered medically necessary for persons with persistent or recurrent junctional reflux. These procedures are considered cosmetic for all other indications.

Additional procedures including ligation or sclerotherapy performed in the same treatment session on the same ablated saphenous vein are included in the reimbursement of the ablation procedure. 

Procedures on other saphenous vein systems are eligible for reimbursement based on multiple surgery guidelines. Please refer to Medical Policy Bulletin, S-100, for information on Multiple Surgical Procedures.

Endovenous radiofrequency obliteration of veins (VNUS), laser obliteration, and endomechanical ablation of incompetent veins (EVLT) include imaging guidance. Ultrasound performed within six months following the most recent ipsilateral treatment, in the absence of complications, is considered not medically necessary, including but not limited to, routine confirmation studies following endovenous/endomechanical ablation.

Endovenous radiofrequency obliteration of veins (VNUS), laser obliteration, and endomechanical ablation of incompetent veins also include catheter insertion as part of the overall procedure.

Sclerotherapy (36470, 36471) 
Treatment decisions for the use of sclerotherapy should be based upon the CEAP classification system. Sclerotherapy of the superficial system veins, short saphenous vein and saphenous tributaries including accessory saphenous veins, may be considered medically necessary when the following criteria are met:

1. Related incompetent superficial system veins(reflux) proximal to the incompetent vein to be treated either have been or are being treated concurrently
2. All of the general criteria (1-6) above outlining when treatment for symptomatic varicose veins is eligible for reimbursement are met
3. Varicose veins are ≥ 5 mm in diameter
4. CEAP clinical classification C 3-6,Symptomatic 

Coverage for sclerotherapy for these indications is limited to a maximum of three (3) sclerotherapy treatment sessions per leg, without additional clinical documentation, when performed within 12 months of the initial invasive varicose vein procedure. The number of medically necessary sclerotherapy injection sessions varies with the number of anatomical areas that have to be injected, as well as the response to each injection. Usually one to three injections are necessary to obliterate any vessel, and 10 to 40 vessels, or up to a maximum of 20 injections in each leg, may be treated in any one session. Requests for additional sclerotherapy sessions are subject to medical necessity review.

Sclerotherapy of the following veins is considered experimental/investigational, and therefore, non-covered. A participating, preferred, or network provider can bill the member for the non-covered service:

1. The long saphenous vein
2. Perforator veins

Sclerotherapy of small veins (less than 5mm in diameter), superficial reticular veins and/or telangiectasias (spider veins) is considered cosmetic, and therefore, non-covered.

Requests for additional sclerotherapy treatment, extending beyond the maximum three (3) treatment sessions per leg, may be considered for coverage when ALL of the following additional criteria have been met.  All documentation must be maintained in the patient's medical record and available upon request:

• additional documentation confirms persistence of symptoms despite prior invasive treatment
• Doppler or Duplex reports and/or standing photographs confirm persistent veins ≥ 5 mm in diameter
• evidence of a clearly defined treatment plan including the procedure codes for the planned intervention

Requests for treatment sessions extending beyond one year from the initial invasive treatment session may be similarly subject to a new medical necessity review. All documentation must be maintained in the patient's medical record and available upon request.

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.
 
Ultrasound or duplex scanning is considered medically necessary when initially performed to determine the extent and configuration of varicose veins. However, ultrasound or radiologically guided or monitoring techniques are not considered medically necessary and are not separately payable when performed solely to guide the needle or introduce the sclerosant into the varicose veins.

Sclerotherapy should be reported under codes 36470 for one vein or 36471 for multiple veins on the same leg. Codes 36470 and 36471 should be reported only once per leg.

Surgical treatment of varicose veins on the contralateral extremity is eligible only if that leg is also symptomatic.

Reimbursement for codes 36470 and 36471 includes the cost of the sclerosing agent; therefore, when code J3490 is reported in addition to code 36470 or 36471, no additional allowance will be made. Modifier 59 may be reported with code J3490 to identify it as a significant, separately identifiable service from the sclerotherapy. When the 59 modifier is reported, the patient's records must clearly document that an injection was provided as a separately identifiable service. Also when reporting code J3490, please include the name of the drug in the narrative section of the electronic or paper claim.

Subfascial Endoscopic Perforator Surgery (SEPS)(37500)
Subfascial endoscopic perforator surgery (SEPS) may be considered medically necessary when the following criteria are met:

• All of the general criteria (1-6) above outlining when treatment for symptomatic varicose veins is eligible for reimbursement are met.
• There is documented Doppler evaluation and/or Duplex ultrasonography of the incompetent perforator vein and it is located on the medial aspect of the calf being treated.
• There is documentation of at least one of the following conditions:
  1. Venous stasis dermatitis/ulceration
  2. Chronic venous insufficiency

SEPS is considered cosmetic, and therefore, non-covered for all other indications including, but not limited to, the treatment of venous insufficiency as a result of post-thrombotic syndrome.

Non-Covered Services

Echosclerotherapy (S2202)
Because ultrasound-monitored or duplex-guided techniques for sclerotherapy of varicose veins (echosclerotherapy) have not been to shown to definitively increase the effectiveness or safety of this procedure, echosclerotherapy 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.

Treatment of Spider Veins (36468 and 36469, 37799) 
Treatment for reticular veins and/or superficial telangiectases, including laser, is considered cosmetic, and therefore, non-covered.

• The injection of sclerosing solution into telangiectases 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).

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

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

Non-Invasive Laser Treatment (37799)
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 considered cosmetic, and therefore, non-covered.

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

Place of Service: Outpatient

Treatment of varicose veins are typically outpatient procedures which are only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, complications related to these procedures.

Description

The venous system of the lower extremities consists of the superficial system (e.g., long and short saphenous veins and saphenous tributaries) and the deep system (e.g., popliteal and femoral veins). These two parallel systems are interconnected via perforator veins and at the saphenofemoral and the saphenopopliteal junctions.

The long and short saphenous veins are also known as the great or greater and the small or lesser saphenous veins, respectively. This policy uses the nomenclature long saphenous vein and short saphenous vein as these terms are consistent with current CPT nomenclature.

One-way valves are present within all veins to direct the return of blood up the lower limb. Larger varicose veins, many protruding above the surface of the skin, typically are related to valve incompetence. As the venous pressure in the deep system is generally greater than that of the superficial system, valve incompetence leads to increased hydrostatic pressure transmitted to the unsupported superficial vein system. Backflow (venous reflux) with pooling of blood ultimately results in varicosities. In addition, clusters of varicosities may appear related to incompetent perforating veins, such as Hunter and Dodd, located in the mid- and distal thigh, respectively and/or associated with incompetence at the saphenofemoral junction. In some instances, the valvular incompetence may be isolated to a perforator vein, such as the Boyd perforating vein located in the anteromedial calf. These varicosities are often not associated with saphenous vein incompetence since the perforating veins in the lower part of the leg do not communicate directly with the saphenous vein.

Although many varicose veins are asymptomatic, when present, symptoms include itching, heaviness, and pain. In addition, chronic venous insufficiency secondary to venous reflux can lead to peripheral edema, hemorrhage, thrombophlebitis, venous ulceration, and chronic skin changes.

Treatment of venous reflux/venous insufficiency is aimed at reducing abnormal pressure transmission from the deep to the superficial veins. Varicose veins can usually be treated with non-surgical measures. Symptoms often decrease when the legs are elevated periodically, when prolonged standing is avoided, and when elastic compression stockings are worn.

If conservative treatment measures fail, additional treatment options typically focus first on identifying and correcting the site of reflux, and second on redirecting venous flow through veins with intact valves. Thus conventional surgical treatment of varicosities is based on the following three principles:

• Control of the most proximal point of reflux, typically at the saphenofemoral junction, as identified by preoperative Doppler ultrasonography. Surgical ligation and division of the saphenofemoral or saphenopopliteal junction is performed to treat the valvular incompetence.
• Removal or occlusion by ablation of the refluxing long and/or short saphenous vein from the circulation. The classic strategy for isolation is vein stripping in conjunction with vein ligation and division.
• Removal or occlusion of the refluxing varicose tributaries. Strategies for removal include phlebectomy (i.e., ligation/division/stripping, powered phlebectomy, or stab avulsion) or occlusion by injection sclerotherapy; either at the time of the initial treatment, or subsequently.

Over the years various different minimally invasive alternatives to ligation and stripping have been investigated, including sclerotherapy and thermal ablation using radiofrequency energy (high frequency radiowaves), laser energy, or cryoablation (also called cryotherapy).

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.

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