Varicose Vein Procedure Guideline (0100‐GL‐DEPT‐0022‐HS)  Prior authorization does not guarantee payment. Coverage of services is based on member eligibility  and member’s benefits per the medical certificate of coverage at the time services are rendered. 

Varicose Vein Procedure Guideline (0100‐GL‐DEPT‐0022‐HS)  Prior authorization does not guarantee payment. Coverage of services is based on member eligibility  and member’s benefits per the medical certificate of coverage at the time services are rendered. 

Varicose Vein Procedure Guideline (0100‐GL‐DEPT‐0022‐HS) Prior authorization does not guarantee payment. Coverage of services is based on member eligibility and member’s benefits per the medical certificate of coverage at the time services are rendered. Physicians Plus considers varicose vein procedures to be a medically necessary covered benefit with a prior authorization that meets criteria and is performed as an outpatient by a participating provider. Utilization Management (UM) staff collects relevant clinical information from the treating physician and/or practitioner to support accurate and appropriate UM determinations based on benefit coverage and medical necessity. Sources of member specific clinical information includes but is not limited to: • Office and hospital records • A history of the presenting problem • Clinical exams • Diagnostic test results • Treatment plans and progress notes • Consults with the treating provider • Evaluations from other health care practitioners and providers • Photos • Operative and pathology reports • Criteria language related to the request • Certificate language for benefits for the requested service or procedure • Patient characteristics and information • Letter of medical necessity from provider A. The following criteria must be met for approval of surgical treatment: CPT codes: 37700, 37718, 37722, 37735, 37760, 37761 37765, 37766, 37780, 37785 Sclerotherapy CPT codes: 36470, 36471 1. A 3‐month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, compressive therapy, and avoidance of prolonged immobility where appropriate, has failed, AND 2. The patient is symptomatic with varicose veins of at least 3 mm and has one or more of the following: • Pain, aching cramping burning itching and or swelling during activity or after prolonged •
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standing severe enough to impair mobility. Recurrent episodes of superficial phlebitis. Non‐healing skin ulceration. Bleeding from a varicosity. Stasis dermatitis. Refractory dependent edema. 3. The treatment of spider veins/telangiectasis (36468) will be considered medically necessary only if there is associated hemorrhage (IDC‐9 459.0). 4. If sclerotherapy is used with endovenous ablation, it may be covered if the criteria for reasonable and necessary as described in this guideline are met. This applies to varicose veins in the same leg as the endovenous ablation done on the day of the ablation or within the first 6 months after the ablation. Any need for sclerotherapy to treat residual varicose veins after this period would then need to have an additional 3 months of conservative treatment and meet the other criteria as outlined above. B. Indications for ERFA or laser ablation (CPT codes 36475, 36476, 36478, 36479): In addition to the above (see A), the patient's anatomy and clinical condition are amenable to the proposed treatment including ALL of the following: •
Absence of aneurysm in the target segment. • Maximum vein diameter of 20 mm for ERFA or 30 mm for laser ablation. • Absence of thrombosis or vein tortuosity, which would impair catheter advancement. • The absence of significant peripheral arterial diseases. C. Limitations for ERFA and laser ablation: •
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ERFA and laser ablation are covered only for the treatment of symptomatic varicosities of the lesser or greater saphenous veins and their tributaries which have failed 3 months of conservative therapy. Intra‐operative ultrasound guidance is not separately payable with ERFA, laser ablation. The treatment of asymptomatic varicose veins, or symptomatic varicose veins without a 3‐
month trial of conservative measures, by any technique, will be considered cosmetic and therefore not covered. The treatment of spider veins or superficial telangiectasis by any technique is also considered cosmetic, and therefore not covered unless there is associated bleeding. Coverage is only for devices specifically FDA‐approved for these procedures. One pre‐operative Doppler ultrasound study or duplex scan will be covered. Post‐procedure Doppler ultrasound studies will be allowed if medically necessary. Physicians Plus considers one post‐procedure Doppler ultrasound within the first week medically necessary to rule out DVT. The stab phlebectomy of the same vein performed on the same day as endovenous radiofrequency or laser ablation may be covered if the criteria for reasonable and necessary as described in this LCD are met. Number of treatments will be limited to 3 visits (one surgical or endovenous ablation session + 2 sessions for sclerotherapy). If 2 legs are involved and meet criteria, a total of 4 visits may be allowed (one surgical or endovenous ablation session per leg + 2 sessions for sclerotherapy). The treatment of asymptomatic veins with endoluminal ablation or sclerotherapy is not considered medically reasonable and necessary. If it is determined on review that the varicose veins were asymptomatic, the claim will be denied as a noncovered (cosmetic) procedure. REFERENCES: Treatment of Varicose Veins of the Lower Extremities (L30143) http://www.wpsmedicare.com/part_b/policy/active/local/130143_gsurg041.shtml Silberzweig JE, Funaki BS, Ray CE Jr, Burke CT, Kinney TB, Kostelic JK, Loesberg A, Lorenz JM, Mansour MA, Millward SF, Nemcek AA Jr, Owens CA, Reinhart RD, Vatakencherry G, Expert Panel on Interventional Radiology. ACR Appropriateness Criteria® treatment of lower‐extremity venous insufficiency. [online publication]. Reston (VA): American College of Radiology (ACR); 2009. CPT/HCPCS Codes 36468
SINGLE OR MULTIPLE INJECTIONS OF SCLEROSING SOLUTIONS,
SPIDER VEINS (TELANGIECTASIA); LIMB OR TRUNK
36470
INJECTION OF SCLEROSING SOLUTION; SINGLE VEIN
36471
INJECTION OF SCLEROSING SOLUTION; MULTIPLE VEINS, SAME
LEG
36475
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN,
EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND
MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN
TREATED
36476
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN,
EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND
MONITORING, PERCUTANEOUS, RADIOFREQUENCY; SECOND AND
SUBSEQUENT VEINS TREATED IN A SINGLE EXTREMITY, EACH
THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN
ADDITION TO CODE FOR PRIMARY PROCEDURE)
36478
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN,
EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND
MONITORING, PERCUTANEOUS, LASER; FIRST VEIN TREATED
36479
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN,
EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND
MONITORING, PERCUTANEOUS, LASER; SECOND AND
SUBSEQUENT VEINS TREATED IN A SINGLE EXTREMITY, EACH
THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN
ADDITION TO CODE FOR PRIMARY PROCEDURE)
37500
VASCULAR ENDOSCOPY, SURGICAL, WITH LIGATION OF
PERFORATOR VEINS, SUBFASCIAL (SEPS)
37700
LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT
SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS
37718
LIGATION, DIVISION, AND STRIPPING, SHORT SAPHENOUS VEIN
37722
LIGATION, DIVISION, AND STRIPPING, LONG (GREATER)
SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE
OR BELOW
37735
LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG OR
SHORT SAPHENOUS VEINS WITH RADICAL EXCISION OF ULCER
AND SKIN GRAFT AND/OR INTERRUPTION OF COMMUNICATING
VEINS OF LOWER LEG, WITH EXCISION OF DEEP FASCIA
37760
LIGATION OF PERFORATOR VEINS, SUBFASCIAL, RADICAL (LINTON
TYPE), INCLUDING SKIN GRAFT, WHEN PERFORMED, OPEN,1 LEG
37761
LIGATION OF PERFORATOR VEIN(S), SUBFASCIAL, OPEN,
INCLUDING ULTRASOUND GUIDANCE, WHEN PERFORMED, 1 LEG
37765
STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20
STAB INCISIONS
37766
STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE
THAN 20 INCISIONS
37780
LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT
SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE)
37785
LIGATION, DIVISION, AND/OR EXCISION OF VARICOSE VEIN
CLUSTER(S), 1 LEG
37799
UNLISTED PROCEDURE, VASCULAR SURGERY
93965
NONINVASIVE PHYSIOLOGIC STUDIES OF EXTREMITY VEINS,
COMPLETE BILATERAL STUDY (EG, DOPPLER WAVEFORM
ANALYSIS WITH RESPONSES TO COMPRESSION AND OTHER
MANEUVERS, PHLEBORHEOGRAPHY, IMPEDANCE
PLETHYSMOGRAPHY)
93970
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO
COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL
STUDY
93971
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO
COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED
STUDY
Guideline Last Updated: January 31, 2012