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.

The following are the medical definitions for the terms in this Medical Policy under the section of Criteria for Specific Procedures:

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

• Chemical adhesive (also known as glue embolization, glue adhesive ablation or cyanoacrylate adhesive) is a procedure where an embolic agent is injected into the vein. The embolic agent polymerizes upon contact with blood and causes the adhesive to form a solid, permanent implant, thus closing the vein. There is no tumescent local anesthesia required, minimizing risks and no postoperative compression therapy required.
• The technique of cyanoacrylate closure (CAC), which is one of the most common liquid embolic agents, uses a proprietary adhesive for the treatment of refluxing saphenous veins.

Echosclerotherapy:

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

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

Radiofrequency ablation (RFA) is a minimally invasive endovenous thermal ablation procedure that involves using ultrasound guidance to puncture the vein, position a catheter and perform tumescent anesthesia. Radiofrequency current is delivered resulting in heat destruction while an inflammatory response enhances wall destruction. The purpose of RFA is to damage the collagen of the vein wall resulting in fibrosis and occlusion of a vein segment to eliminate reflux. This procedure may be performed in the outpatient setting.

• ELVA/EVLT is a minimally invasive alternative to high ligation and saphenous vein stripping HL/S. It is only a treatment option for sufficiently straight superficial vein segments that will allow passage of the device. The purpose of ELVA/EVLT is to damage the endothelium of the vein resulting in fibrosis and occlusion of a vein segment to eliminate reflux. The thermal ablation techniques are appropriate for the primary treatment of the greater saphenous vein (GSV) and/or smaller saphenous vein (SSV), and incompetent accessory saphenous veins.

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

• The traditional treatment of varicose veins in the lower legs includes a surgical procedure called (HL/S). Its primary goal is removal of refluxing veins and improvement of symptoms. HL/S is typically a three-step process. The first step is controlling reflux by proximal ligation of an incompetent vein. The second step is stripping a vein segment (usually the GSV or SSV) or removing of an incompetent long axial vein segment (usually the saphenous vein) from circulation through incisions in the groin and lower in the leg. The third step is removing tributaries via stab phlebectomies or sclerotherapy, either at the time of ligation or subsequent to the ligation. Phlebectomy, also referred to as stab avulsion, ambulatory stab phlebectomy, or microphlebectomy, is a surgical treatment involving the removal of varicose veins through small “stab” 1-2 mm incisions in the skin overlying the vein. The vein is hooked and brought to the surface at each incision site to release it from the surrounding tissues and to sever any connections to other veins.

Mechanochemical Ablation (MOCA/MECA):

• MOCA/MECA is a technique used to ablate superficial veins with an oscillating wire that rotates and disrupts the endothelial lining of target veins while a sclerosant is injected to penetrate the deep layers of the vein causing vein sclerosis. This technique is appropriate for the treatment of truncal veins.

Sclerotherapy (Liquid or Microfoam):

• Sclerotherapy is a treatment of the veins using liquid sclerosant agents or sclerosing foam. Sclerosing agents are chemical agents that cause endothelial damage leading to sclerosis of the venous segment once it is injected into the vein lumen. Sclerosing foam is made from a sclerosant agent and a gas.

Liquid Sclerosant:

• Liquid sclerosant is often used to treat cosmetic telangiectasias and reticular veins. Liquid sclerotherapy is also of value in addressing bleeding telangiectasias and for select cases of large vein treatment where unique individual features suggest liquid may be a safer option.
• Some examples (not all inclusive) of agents for sclerotherapy include sodium tetradecyl sulfate (STS), polidocanol, sodium morrhuate, and glycerin, which is typically used with epinephrine.

Foam Sclerosant: Ultrasound-Guided Foam Sclerotherapy (UGFS):

• Foam sclerosant is a procedure that is performed under ultrasound guidance. There are different types of foam: physician-compounded foam (PCF) and non-compounded foam (NCF). The target, non-target, perforating, and adjacent deep veins are evaluated by ultrasound. UGFS is used for treatment of primary and recurrent varicose veins, including the distal GSV and SSV, perforating veins, and venous malformations.

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

General medical necessity criteria for coverage of symptomatic varicose veins.

• The individual has ANY 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
  • Hemorrhage from ruptured superficial varicosities; or
  • Recurrent superficial thrombophlebitis that fails to respond to conservative treatment; or
  • Ulceration secondary to venous stasis; and

• Clinical documentation must indicate at least three (3) months of failed conservative treatment and include ALL of the following:
  • Clinical, etiology, anatomy, pathophysiology (CEAP) class C₂ or greater; and
  • Gradient compression garments providing a minimum of 20-30 mmHg pressure; and
  • Leg elevation; and
  • Walking/exercising as tolerated; and

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

Doppler 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: 
• Absence of deep venous thrombosis (DVT); and
•  Augmentation; and
• Compressibility; 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  
• Visibility.

Treatment Sessions:

• Initial treatment: unilateral or bilateral may be considered medically necessary when the individual meets the above criteria.
• Additional may be medically necessary treatments after the initial session if all the following criteria are met:
  • Individual meets the coverage criteria for medical necessity as outlined above; and
  • Previously established conservative treatments for vein procedures.

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. 

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

Treatment of symptomatic varicose veins not meeting the general medical necessity criteria as indicated in this policy is considered not medically necessary.

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 and accessory veins; one (1) session for the left great saphenous vein or one (1) session for the right great saphenous vein, totaling two (2) sessions in a 12 month period; and
• One (1) treatment session each of the small saphenous and accessory veins; one (1) session for the left small saphenous vein or one (1) session for the right small saphenous vein, totaling two (2) sessions in a 12 month period.

Treatment of the great saphenous and the small saphenous and accessory veins with cyanoacrylate adhesive not meeting the criteria as indicated in this policy is considered cosmetic and therefore non-covered.

Cyanoacrylate adhesive is considered cosmetic when the frequency guideline listed above is exceeded.

Cyanoacrylate adhesive for great saphenous, small saphenous and accessory saphenous veins,

that exceeds the frequency guidelines listed on the policy are considered not medically necessary.

For accessory saphenous veins criteria, see Accessory Saphenous Veins.

Echosclerotherapy

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.

Echosclerotherapy not meeting the criteria as indicated in this policy is considered not medically necessary. 

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

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 and accessory veins; one (1) session for the left great saphenous vein or one (1) session for the right great saphenous vein, totaling two (2) sessions in a 12 month period; and
• One (1) treatment session each of the small saphenous and acessory veins; one (1) session for the left small saphenous vein or one (1) session for the right small saphenous vein, totaling two (2) sessions in a 12 month period.

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

For criteria related to perforator veins, see Perforator Veins.

For accessory saphenous veins criteria, see Accessory Saphenous Veins.

Endovenous ablation procedures for the treatment of the great saphenous and accessory and the small saphenous veins not meeting the criteria as indicated in this policy is considered cosmetic and therefore non-covered.

Endovenous ablation procedures considered cosmetic when the frequency guideline listed above is exceeded.

Endovenous ablation procedures for great saphenous, small saphenous and accessory saphenous veins, that exceeds the frequency guidelines listed on the policy are considered not medically necessary.

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.

Ligation and stripping, ambulatory phlebectomy (i.e., stab, hook, transilluminated powered) for conditions other than symptomatic veins, not meeting the criteria as indicated in this policy is considered cosmetic and therefore non-covered.

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 C2-C6; and
• When ALL of the general medically necessary criteria above are met; or
• If there are bleeding varicosities smaller than five (5) mm.

Sclerotherapy performed on the small saphenous veins or saphenous tributaries (including saphenous veins) not meeting the criteria as indicated in this policy is considered cosmetic and therefore non-covered.

Sclerotherapy (liquid or microfoam) procedures for the treatment not meeting the criteria as indicated in this policy is considered cosmetic and therefore non-covered.

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.

• 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 confirm persistent veins at least five (5) mm in diameter; or
• If there are bleeding varicosities smaller than five (5) mm.

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.
• One (1) treatment session each of the great saphenous and accessory veins; one (1) session for the left great saphenous vein or one (1) session for the right great saphenous vein, totaling two (2) sessions in a 12 month period; and
• One (1) treatment session each of the small saphenous and acessory veins; one (1) session for the left small saphenous vein or one (1) session for the right small saphenous vein, totaling two (2) sessions in a 12 month period.

Non-covered

Treatment of accessory saphenous veins by ligation and stripping, endovenous radiofrequency, laser ablation, or cyanoacrylate not meeting criteria as indicated in this policy is considered cosmetic and therefore non-covered.

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

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

Ligation or ablation of incompetent perforator veins performed not meeting the criteria as indicated in this policy is considered not medically necessary.

SEPS, endovenous radiofrequency or laser ablation performed on perforator veins  not meeting the criteria as indicated in this policy is considered cosmetic and therefore non-covered.

The following are considered Non-Covered Services:

Endovenous Cryoablation

Endovenous cryoablation not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered. because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

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, not meeting criteria as indicated in this policy is considered cosmetic and therefore non-covered.

Laser treatment/non-invasive not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered. because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Mechanochemical Ablation (MCA/MOCA)

Mechanochemical ablation not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered. because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Spider Veins, Treatment

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

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

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

The standard classification of venous disease is the CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) classification system.