A variety of treatment modalities are available to treat varicose veins/venous insufficiency, including surgical approaches, thermal ablation, and sclerotherapy. The application of each of these treatment options is influenced by the severity of the symptoms, type of vein, source of venous reflux, and the use of other (prior or concurrent) treatments.

General medical necessity criteria for coverage of symptomatic varicose veins

Treatment for symptomatic varicose veins may be considered medically necessary when ALL of the following criteria are met for all varicose vein treatments:

• The individual has ANY ONE of the following:
  • Documented limitations of activities of daily living caused by persistent lower extremity symptoms such as aching, pain, tightness, skin irritation, heaviness, muscle cramps, etc., that fail to respond to conservative treatments; or
  • Ulceration secondary to venous stasis; or
  • Hemorrhage from ruptured superficial varicosities; or
  • Recurrent superficial thrombophlebitis that fails to respond to conservative treatment; and

• Clinical documentation must indicate at least three (3) months of failed conservative treatment and include ALL of the following:

o    Gradient compression garments providing a minimum of 20-30 mmHg pressure; and

o    Leg elevation; and

o    Walking/exercising as tolerated; and

o   Clinical, etiology, anatomy, pathophysiology (CEAP) class C2 or greater; and

     (Conservative treatment is not required in cases of CEAP levels five (5) and six (6))

• Venous imaging studies documenting any incompetence/reflux in the superficial system veins (great saphenous veins, small saphenous veins and saphenous tributaries); and

Imaging Requirements:

• Doppler ultrasound or duplex study must be performed no more than 12 months prior to the procedure and include documentation of ALL of the following:
• Visibility; and
• Compressibility; and
• Augmentation; and
• Absence of an acute deep venous thrombosis (DVT); and
• Reflux where at least ONE of the following is present:
  • At least 500 msec for saphenous, tibial, deep femoral  and perforating veins; or
  • At least one (1) second for femoral and popliteal veins;  and
• Vein size at least five (5) mm; and  

Treatment Sessions:

• Initial treatment: unilateral or bilateral.
• Additional treatments after the initial session:
  • Must meet ALL coverage criteria as outlined above; and
  • No need to document new conservative treatments if they were previously established for vein procedure and documented;
• Endovenous ablation or cyanoacrylate adhesive:
  • One treatment session each of the greater saphenous vein; one session for the left greater saphenous vein or one session for the right greater saphenous vein, totaling two (2) sessions.
  • One treatment session each of the small saphenous vein; one session for the left small saphenous vein or one session for the right small saphenous vein, totaling two (2) sessions.

Follow-up Imaging

• Follow-up venous studies may be considered medically necessary within 48-72 hours after endovenous ablation for the purpose of excluding a DVT.  ALL other follow-up venous studies or ultrasounds performed within six (6) months following the most recent ipsilateral treatment, in the absence of complications, are considered not medically necessary.
• Follow-up venous studies or ultrasound performed six (6) months or longer following the most recent ipsilateral treatment may be considered medically necessary when ALL of the other general criteria above are met.

Intraoperative ultrasound guidance, when performed, is an integral part of the primary procedure and is not separately reimbursed.

Accepted Procedures

When conservative treatments fail to provide relief from symptomatic venous insufficiency and ALL of the above general criteria requirements are met, the following options may be considered medically necessary when reported for symptomatic varicose veins. However, in addition to the general medically necessary criteria above, specific requirements for each procedure must also be met:

• Ligation/stripping and ambulatory phlebectomy (i.e., stab, hook, transilluminated powered)
• Endovenous radiofrequency, endovenous laser ablation/treatment (EVLA/EVLT) and endomechanical ablation 
• Echosclerotherapy
• Sclerotherapy (liquid or microfoam) 
• Subfascial endoscopic perforator surgery (SEPS) 
• Cyanoacrylate

If general medical necessity criteria are not met, see specific procedures and treatment of specific veins below for appropriate denial criteria.

Criteria for Specific Procedures

Cyanoacrylate Adhesive (Great Saphenous, Small Saphenous and Accessory Saphenous Veins)

Treatment of the great saphenous or small saphenous veins with cyanoacrylate adhesive may be considered medically necessary for symptomatic varicose veins/venous insufficiency when ALL of the following criteria are met:

·      Great saphenous vein symptoms including but not limited to leg/ankle swelling, skin changes, or a venous stasis ulcer; or

·      Small saphenous vein symptoms including but not limited to lateral ankle and foot swelling, or a venous stasis ulcer; and

·      ALL of the general medically necessary criteria above are met; and

·      One (1) treatment session each of the great saphenous veins; one (1) session for the left great saphenous or one (1) session for the right great saphenous, totaling two (2) sessions; and

·      One (1) treatment session each of the small saphenous veins; one (1) session for the left small saphenous or one (1) session for the right small saphenous, totaling two (2) sessions.

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

Procedures on other saphenous vein systems are eligible for reimbursement based on multiple surgery guidelines.

Treatment of the great saphenous veins and small saphenous veins with cyanoacrylate adhesive not meeting the above criteria is considered cosmetic and therefore non-covered.

For accessory saphenous veins criteria, see Accessory Saphenous Veins.

Echosclerotherapy

Echosclerotherapy is a technique used for perforator veins. Duplex ultrasound guidance is used to inject a sclerosing agent into varicose veins. 

Echosclerotherapy may be considered medically necessary when BOTH of the following criteria have been met:

• Perforator vein size at least 3.5 mm in diameter; and
• CEAP Class C5-C6.

Code S2202 includes the cost of ultrasound guidance therefore when code 76942 is reported in addition to code S2202 no additional allowance will be made.

Echosclerotherapy performed for any other indication is considered not medically necessary.

Endovenous Radiofrequency, Endovenous Laser Ablation/Treatment (EVLA/EVLT) and Endomechanical Ablation

Treatment of the great saphenous veins and small saphenous veins may be considered medically necessary when ALL of the following criteria are met:

• Great saphenous vein symptoms including but not limited to leg/ankle swelling, skin changes, or a venous stasis ulcer; or
• Small saphenous vein symptoms including but not limited to lateral ankle and foot swelling, or a venous stasis ulcer; and
• ALL of the general medically necessary criteria above are met; and
• One (1) treatment session each of the great saphenous veins; one (1) session for the left great saphenous vein or one (1) session for the right great saphenous vein, totaling two (2) sessions; and
• One (1) treatment session each of the small saphenous veins; one (1) session for the left small saphenous vein or one (1) session for the right small saphenous vein, totaling two (2) sessions

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.

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

For criteria related to perforator veins, see Perforator Veins

Endovenous ablation procedures for the treatment of the great saphenous and the small saphenous veins for all other conditions are considered cosmetic and therefore non-covered.

Ligation and Stripping and Phlebectomy (i.e., Stab, Hook, Transilluminated Powered)

Treatment of the great saphenous veins, small saphenous veins and/or saphenous tributaries may be considered medically necessary when the following criteria are met:

• Related incompetent superficial veins proximal to the incompetent vein to be treated either have been or are being treated concurrently; and
• ALL of the general medical necessary criteria above 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 and stripping, ambulatory phlebectomy (i.e., stab, hook, transilluminated powered) for conditions other than symptomatic veins, are considered cosmetic, and therefore, non-covered. This includes the diagnosis of non-symptomatic varicose veins.

Sclerotherapy (Liquid or Microfoam)

Sclerotherapy may be considered medically necessary for the treatment of the small saphenous veins or saphenous tributaries, including accessory saphenous veins when ALL of the following criteria are met:

• Related incompetent superficial system veins (reflux) proximal to the incompetent vein to be treated either have been or are being treated concurrently; and
• CEAP Class C3-C6; and
• ALL of the general medically necessary criteria above are met.

Sclerotherapy performed on the small saphenous veins or saphenous tributaries (including saphenous veins) not meeting the criteria above will be considered cosmetic.

Non-covered

Sclerotherapy (liquid or microfoam) of the great saphenous vein and perforator veins is considered experimental/investigational and therefore non-covered due to lack of supporting scientific evidence.

Sclerotherapy (liquid or microfoam) of the following veins is considered cosmetic and therefore non- covered;

• Small veins less than five (5) mm in diameter; or
• Superficial reticular veins and/or telangiectasia veins (spider veins).

Coverage for sclerotherapy (liquid or microfoam) for these indications is limited to a maximum of three (3) sclerotherapy treatment sessions per leg: three (3) treatment sessions for the right leg and three (3) sessions for the left leg.  A total of six (6) sessions may be authorized to treat these veins 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 (1) to three (3) injections is necessary to obliterate any vessel, and 10 to 40 vessels, or a set of up to a maximum of 20 injections in each leg, may be treated in any one (1) session.
• Requests for additional sclerotherapy sessions are subject to medical necessity review.

Requests for additional sclerotherapy (liquid or microfoam) treatment, extending beyond the maximum three (3) treatment sessions per leg, may be considered medically necessary  when ALL of the following additional criteria have been met.

• Additional documentation confirms persistence of symptoms despite prior invasive treatment; and
• Doppler or Duplex reports and/or standing photographs confirm persistent veins at least five (5) mm in diameter; and
• Evidence of a clearly defined treatment plan including the procedure codes for the planned intervention.

Requests for treatment sessions extending beyond one year (12 months) from the initial invasive treatment session may be similarly subject to a new medical necessity review.

Reimbursement

• 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 may be considered medically necessary when initially performed to determine the extent and configuration of varicose veins. However, ultrasound or radiologically guided or monitoring techniques are considered not medically necessary when performed solely to guide the needle or introduce the sclerosant into the varicose veins.
• Surgical treatment of varicose veins on the contralateral extremity may be considered medically necessary only if that leg is also symptomatic.

Code 36470

• Sclerotherapy for one (1) vein on the same leg.
• Report this code only once per leg per session.
• Includes the cost of the sclerosing agent.
• Surgical treatment of varicose veins on the contralateral extremity may be considered medically necessary only if that leg is also symptomatic.

Code 36471

• Sclerotherapy for multiple veins on the same leg.
• Report this code only once per leg per session.
• Includes the cost of the sclerosing agent.
• Surgical treatment of varicose veins on the contralateral extremity may be considered medically necessary only if that leg is also symptomatic.

Code J3490

• Code 36470 and 36471 both include the cost of the sclerosing agent.  When J3490 is reported in addition to either 36470 or 36471 no additional allowance will be made.
• When reporting code J3490, please include the name of the drug in the narrative section of the electronic or paper claim.
• 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, records must clearly document that an injection was provided as a separately identifiable service.

Treatments of Specific Vein Types

Accessory Saphenous Veins

Treatment of accessory saphenous veins by ligation and stripping, endovenous radiofrequency,  laser ablation or cyanoacrylate adhesive may be considered medically necessary for symptomatic varicose veins/venous insufficiency when ALL of the following criteria have been met:

• Incompetence of the accessory saphenous vein is isolated or the great saphenous vein or small saphenous vein has been previously eliminated (at least three (3) months); and
• There is demonstrated accessory saphenous reflux; and
• Ultrasound demonstrates vein size at least five (5) mm in diameter; and
• There is documentation of ANY ONE of the following:
  • Ulceration secondary to venous stasis; or
  • Recurrent superficial thrombophlebitis that fails to respond to conservative therapy; or
  • Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity; or
  • Symptomatic varicose veins (as defined above) AND supporting clinical documentation.

Non-covered

Treatment of accessory saphenous veins by ligation and stripping, endovenous radiofrequency, or laser ablation, or cyanoacrylate that do not meet the coverage criteria described above is considered cosmetic and therefore non-covered.

Greater Saphenous Vein Treatments (see Criteria for Specific Procedures above)

Ligation and stripping and phlebectomy (i.e., stab, hook, transilluminated powered), endovenous radiofrequency, endovenous laser ablation/treatment (EVLA/EVLT),  endomechanical ablation, or cyanoacrylate adhesive.

Perforator Veins:  Subfascial endoscopic perforator surgery (SEPS) or endovenous radiofrequency or laser ablation may be considered medically necessary as a treatment of leg ulcers associated with chronic venous insufficiency when the following criteria have been met;

• There is demonstrated perforator reflux; and
• The superficial saphenous veins (great saphenous vein, small saphenous vein, or accessory saphenous veins and symptomatic varicose tributaries) have been previously eliminated; and
• Ulcers have not resolved following combined superficial vein treatment and compression therapy for at least three (3) months; and
• The venous insufficiency is not secondary to a DVT.

Ligation or ablation of incompetent perforator veins performed concurrently with superficial venous surgery is not considered not medically necessary.

SEPS, endovenous radiofrequency or laser ablation performed on perforator veins that do not meet the criteria above will be considered cosmetic and therefore non-covered.

Saphenous Tributaries (see Criteria for Specific Procedures above)

Ligation and stripping and phlebectomy (i.e., stab, hook, transilluminated powered) or sclerotherapy (liquid or microfoam).

Small Saphenous Vein Treatments (see Criteria for Specific Procedures above)

Ligation and stripping and phlebectomy (i.e., stab, hook, transilluminated powered), endovenous radiofrequency, endovenous laser ablation/treatment (EVLA/EVLT), endomechanical ablation or sclerotherapy (liquid or microfoam) or cyanoacrylate

Non-Covered Services

Endovenous Cryoablation

Endovenous cryoablation of any vein is considered experimental/investigational and therefore non- covered.  Scientific evidence does not demonstrate the effectiveness of this treatment.

Laser Treatment, Non-Invasive

Non-invasive laser treatment, e.g., Vasculite Nd Yag, intense pulsed light (IPL), performed on small superficial, reticular, and telangiectatic veins is considered cosmetic and therefore non-covered.

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.

Mechanochemical Ablation (MCA)/(MOCA)

Mechanochemical ablation of any method, of any vein (i.e., ClariVein® system) is considered experimental/investigational and therefore non-covered. Scientific evidence does not demonstrate the safety and efficacy of this treatment.

Spider Veins, Treatment

Treatment for reticular veins and/or superficial telangiectasia’s, including laser, is considered cosmetic, and therefore, non-covered.

• The injection of sclerosing solution into telangiectasia’s such as spider veins, hemangiomata and angiomata should be reported with code 36468.
• Laser destruction of reticular veins and/or telangiectasia’s (e.g., VascuLite) should be reported with code 37799.

Procedure codes 17106, 17107, and 17108 should not be used to report the treatment of reticular veins and/or spider veins.

CEAP Classification System