UPMC Health Plan POLICY AND PROCEDURE MANUAL :

Transcription

UPMC Health Plan
POLICY AND PROCEDURE MANUAL
POLICY NUMBER: PAY.066
REVISION DATE: 07/13
ANNUAL APPROVAL DATE: 09/13
PAGE NUMBER: 1 of 7
SUBJECT:
INDEX TITLE:
ORIGINAL DATE:
Treatment of Varicose Veins
Medical Management
August 2008
This policy applies to the following lines of business: (Check those that apply.)
COMMERCIAL
CMS-MA
DPW-MA
HMO ( )
OH ( )
Health Choices /PH (X)
PPO ( )
WV ( )
Health Choices/BH ( )
Fully Insured ( )
PA ( )
All ( )
Self-funded/ASO ( )
All (X)
WORK PARTNERS
Indiv. Product ( )
HMO (X)
Commercial WC ( )
All (X)
PPO (X)
Disability Svcs/TPA ( )
CSNP (X)
Health Promotion ( )
PID-CHIP
CHIP (X)
DSNP (X)
All ( )
ISNP (X)
Part D ( )
All ( )
I.
ANCILLARY
UPMC Dental Adv. ( )
UPMC Vision Adv. ( )
COBRA ( )
FSA ( )
HSA ( )
HRA ( )
HIA ( )
All ( )
POLICY
It is the policy of UPMC Insurance Services Division to recognize that treatment for
varicose veins for non-cosmetic purposes is consistent with good medical practice when
medically necessary and when performed according to the clinical indications as
described in this policy. Treatments for varicose veins will be covered when conducted
according to the standards established by UPMC Insurance Services Division and the
member’s specific benefit plan.
II.
DEFINITIONS
Laser Ablation: the removal of a vein or artery using a laser.
Ligation: tying off a large vein.
Phlebectomy (also known as stab or ambulatory phlebectomy): is a minimally
invasive technique for surgical removal of varicose veins through tiny incisions in the
skin overlaying the vein.
Sclerotherapy: the injection of a sclerotic solution to treat varicose veins.
Proprietary and Confidential Information of UPMC Health Plan
© 2013 UPMC All Rights Reserved
PAGE NUMBER: 2 of 7
Stripping: the removal of a vein through incision into the skin.
Varicose Veins: veins that have become enlarged and gnarled and are unable to prevent
blood reflux.
Varix: an enlarged and tortuous vein or artery.
III.
PURPOSE
The purpose of this policy is to outline the indications and limitations for treatment of
varicose veins in order to distinguish between cosmetic treatments versus medical
necessity.
IV.
SCOPE
This policy applies to various UPMC Insurance Services Division departments as
indicated by the Benefit and Reimbursement Committee. These include but are not
limited to: Medical Management, Benefit Configuration and Claims Departments.
V.
PROCEDURE
A. Medical Description
The treatment of varicose veins is intended to relieve symptoms and manage
complications to prevent further health issues. Varicose veins are veins that have become
enlarged and gnarled, and are usually found in the lower extremities, and protrude from
the skin surface. In addition to the pain and discomfort experienced, varicose veins may
lead to serious complications including pulmonary embolism, thrombophlebitis,
hemorrhage, and venous insufficiency and ulceration.
To manage varicose veins, there are conservative treatments for mild symptoms that
include periodic leg elevation, mild exercise and compressive stockings. For severe
varicosities and progressive, long-standing conditions, there are several treatment
options. This policy addresses surgical treatment, radiofrequency endovenous occlusion
(ERFA) & endovenous laser ablation, injection/compression sclerotherapy and subfascial
endoscopic perforator vein surgery (SEPS).
Telangiectasias, or spider veins, which have a web-like appearance on the surface of the
skin, are viewed as cosmetic and not covered by this policy.
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B. Indications for symptomatic varicose vein treatment:
1. Surgical treatment, sclerotherapy, radiofrequency ablation or laser ablation, and
subfascial endoscopic perforator vein surgery (SEPS) for the treatment of varicose
veins of the legs are eligible for payment for those members who meet the following
criteria:
1) A three month trial of supportive therapy ordered by the treating physician
including support/compression hose, leg elevation, weight reduction and mild
exercise where appropriate. Compression stockings are defined as graduated
elasticized compression stockings. Use of non-graduated compression garments
such as support pantyhose does not fulfill this requirement.
2) Duplex studies of the venous system performed by an accredited vascular
technician that fully defines the anatomy, size and tortuosity of the greater and
lesser saphenous vein, superficial venous segments and perforators. 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 patient’s symptoms
3) Any ONE of the following:
 Pain, cramping, aching, itching or burning in the extremity substantial
enough to impair mobility or activities of daily living
 The veins are demonstrable (bulging) above the surface of the skin
 Recurrent superficial phlebitis
 Non-healing skin ulceration of the leg
 Refractory dependent edema or other complications from venous stasis
such as dermatitis
 Hemorrhage from a ruptured varix
*NOTE: Lack of patient compliance with compression stockings does not support
the need for intervention without documentation of other failed conservative
treatments as well.
2. Sclerotherapy (compression) – in addition to the general criteria, when injecting
varicose veins with sclerosing solution, ALL of the following criteria must also be
met:
 There is no sapheno-femoral insufficiency, incompetency or occlusion of
the deep veins
 The varicosities are at least 3mm in size.
 Sclerotherapy may be covered as part of a combination procedure with
surgical ligation and excision.
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3. Radiofrequency endovenous occlusion (ERFA) and endovenous laser
ablation(EVLA) - in addition to the general criteria above, ALL of the following
must be met:
 Patient’s anatomy is amenable to laser or radiofrequency catheter with
absence of vein tortuosity that would impair catheter advancement.
 Maximum saphenous vein diameter is 12 mm (only for ERFA).
 Non-aneurysmal saphenous vein(s).
4. Stab or ambulatory phlebectomy may be medically necessary when the indications
listed above are met for persons whose symptoms and functional problems are
attributable only to the secondary, smaller vessels.
5. SEPS for identified perforator incompetence, may be medically necessary for the
treatment of patients who meet the general indications for varicose vein surgical
stripping listed above as demonstrated by chronic venous insufficiency secondary to
primary valvular incompetence of superficial and perforating veins, with or without
deep venous incompetence, and when conservative treatment has failed.
C. Limitations





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Injection of a sclerosing solution into telangiectasias, (spider veins,
hemangiomata and angiomata) regardless of the anatomical site (leg, face,
trunk) is considered cosmetic and not covered by UPMC HealthPlan.
When performing ligation and division of the long saphenous vein at the
saphenofemoral junction, placement of a percutaneous suture instead of a
true ligation will be denied.
Doppler ultrasound or duplex scans will be required prior to the treatment
to characterize the venous anatomy and pathology (can demonstrate both
the absence of deep venous thrombosis and greater and/or lesser saphenous
vein valvular incompetence/reflux that correlates with the patient’s
symptoms). Ultrasound or duplex scans to guide or monitor during
sclerotherapy will not be covered.
All methods of treatment for asymptomatic varicose veins, superficial
telangiectasias, spider veins, and other superficial vascular anomalies
including sclerotherapy, photothermal sclerosis (Vasculight®) and all
forms of laser treatments are considered cosmetic and not covered.
Non-compressive sclerotherapy is also not covered because this treatment
method has not been shown to be effective in providing long-term
obliteration of the incompetent veins.
Sclerotherapy, with or without ultrasound guidance, is considered
ineffective for treatment of the sapheno-femoral junction or the saphenous
veins, and has not been proven effective in treating larger veins, nor has it
PAGE NUMBER: 5 of 7


been shown to be effective for members with reflux at the saphenofemoral
or saphenopopliteal junctions.
SEPS for the treatment of post-thrombotic syndrome or varicose veins
without identified perforator incompetence is considered
experimental/investigational because the effectiveness for these indications
has not been established.
Transdermal laser treatment of large symptomatic varicose veins is not
covered.
D. Variations
N/A
E. Quality Audit
Quality Audit monitors policy compliance and/or billing accuracy at the request of the
UPMC Insurance Services Division’s Technology Assessment Committee or the Benefits
Reimbursement Committee.
F. Records Retention
Records Retention for documents, regardless of medium, are provided within the UPMC
Health System Policy for Records Retention, Management and Retirement, and as
indicated in the UPMC Insurance Services Division Policy and Procedure for Records
Retention.
G. References
1. Novitas Solutions, LCD 27539 – treatment of Varicose Veins of the Lower
Extremities, 4/2/12. http://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?LCDId=27539&ContrId=170&ver=55&ContrVer=2&CntrctrSelecte
d=170*2&Cntrctr=170&name=Novitas+Solutions%2c+Inc.+(12502%2c+MAC++Part+B)&s=45&DocType=All&bc=AggAAAIAAAAAAA%3d%3d&
2. Ultrasound-guided Sclerotherapy for the Treatment of Varicose Veins. ECRI
Institute; Hotline Response. Published: 07/27/2011.
https://mebmers2.ecri.org/Components/Hotline/Pages/10087.aspx
3. Endovenous Radio-frequency ablation (VNUS Closure System) for the Treatment
of Varicose Veins. ECRI Institute: Evidence Reports. Published 08/24/2006.
https://members2.ecri.org/Components/EvidenceReports/Pages/6889.aspx
4. Biemans A, Kockaert M, Akkersdijk G, et al. Comparing endovenous laser
ablation, foam sclerotherapy, and conventional surgery for great saphenous
varicose veins. J Vasc Surg. 2013 June 13; [Epub ahead of print]
http://dx.doi.org/10.1016/j.jvs.2012.12.074.(http://www.sciencedirect.com/scienc
e/article/pii/S074152141300133X)
PAGE NUMBER: 6 of 7
5. Wright N, Fitridge R. Varicose Veins: Natural history, assessment and
management. Aust Fam Physician. 2013 June; 42(6):380-384.
http://www.racgp.org.au/afp2013//june/varicose-veins/
PAGE NUMBER: 7 of 7
Disclaimer:
UPMC Health Plan medical payment and prior authorization policies do not constitute
medical advice and are not intended to govern or otherwise influence the practice of
medicine. The policies constitute only the reimbursement and coverage guidelines of
UPMC Health Plan and its affiliated managed care entities. Coverage for services varies
for individual members in accordance with the terms and conditions of applicable
Certificates of Coverage, Summary Plan Descriptions, or contracts with governing
regulatory agencies.
UPMC Health Plan reserves the right to review and update the medical payment and prior
authorization guidelines in its sole discretion. Notice of such changes, if necessary, shall
be provided in accordance with the terms and conditions of provider agreements and any
applicable laws or regulations.
These policies are the proprietary information of UPMC Health Plan. Any sale, copying,
or dissemination of said policies is prohibited.

UPMC Health Plan POLICY AND PROCEDURE MANUAL :

Transcription

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