S-55-051

HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

Medical Policy:

S-55-051

Topic:

Surgical Treatment of Varicose Veins

Section:

Surgery

Effective Date:

January 8, 2024

Issued Date:

January 8, 2024

Last Revision Date:

November 2023

Annual Review:

November 2023

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 the related Medical Policies under the Policy Position:

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 Session:

A treatment session (visit) includes the treatment provided on the SAME day to 1 or more veins in the SAME leg.

VEIN ANATOMY

Main Veins: Greater Saphenous Vein (GSV) , Superficial Saphenous Vein/ Long Saphenous Vein (SSV/LSV)
Accessory Veins: Anterior saphenous, Anterior Circumflex, Anterior Branch Lateral saphenous, Posterior Circumflex, Posterior medial branch
Tributary Veins: smaller branches of all of the above listed veins
Perforator Veins: Cockett’s, Boyd’s, Dodd’s, Hunter’s, May’s, Kuster’s
Telangiectasia/Reticular Veins: Spider Veins (considered cosmetic)

COMMON ABBREVIATIONS:

CFV - Common Femoral Vein: normal
PFV - Proximal Femoral Vein
MFV - Mid Femoral Vein
DFV - Distal Femoral Vein: positive compress
Pop V - Popliteal Vein: normal
SFJ - Saphenofemoral Junction: normal
AAGSV - Anterior Accessory Great Saphenous Vein
PAGSV - Posterior Accessory Great Saphenous Vein
PGSV - Proximal Great Saphenous Vein
MGSV - Mid Great Saphenous Vein
AAGSV Calf - Anterior Accessory Great Saphenous Vein Calf
PAGSV Calf - Posterior Accessory Great Saphenous Vein Calf
SPJ - Saphenopopliteal Junction
PSSV - Proximal Small Saphenous Vein
MSSV - Mid Small Saphenous Vein
TESSV - Thigh Extension Small Saphenous Vein

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

Class	Definition
C₀	No visible or palpable signs of venous disease
C₁	Telangiectasies or reticular veins
C₂	Varicose veins
C_2r	Recurrent varicose veins
C₃	Edema
C₄	Changes in skin and subcutaneous tissue secondary to cardiovascular disease (CVD)
C_4a	Pigmentation and eczema
C_4b	Lipodermatosclerosis or atrophie blanche
C_4C	Corona phlebectatica
C₅	Healed
C₆	Active venous ulcer
C_6r	Recurrent active venous ulcer
S	Symptomatic
A	Asymptomatic

Policy Position

Treatment of symptomatic varicose veins using one or more of the following varicose vein treatments may be considered medically necessary when the applicable clinical criteria contained within the related individual treatment modality policy/guideline are met.

Procedure Code	Code Description	Policy/Guideline Number	Policy/Guideline Title
36465	INJECTION OF NON-COMPOUNDED FOAM SCLEROSANT WITH ULTRASOUND COMPRESSION MANEUVERS TO GUIDE DISPERSION OF THE INJECTATE, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING; SINGLE INCOMPETENT EXTREMITY TRUNCAL VEIN (EG, GREAT SAPHENOUS VEIN, ACCESSORY SAPHENOUS VEIN)	HMK S-552	Sclerotherapy (Liquid or Microfoam)
36466	INJECTION OF NON-COMPOUNDED FOAM SCLEROSANT WITH ULTRASOUND COMPRESSION MANEUVERS TO GUIDE DISPERSION OF THE INJECTATE, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING; MULTIPLE INCOMPETENT TRUNCAL VEINS (EG, GREAT SAPHENOUS VEIN, ACCESSORY SAPHENOUS VEIN), SAME LEG	HMK S-552	Sclerotherapy (Liquid or Microfoam)
36468	INJECTION(S) OF SCLEROSANT FOR SPIDER VEINS (TELANGIECTASIA), LIMB OR TRUNK	HMK S-557	Spider Veins, Treatment
36470	INJECTION OF SCLEROSANT; SINGLE INCOMPETENT VEIN (OTHER THAN TELANGIECTASIA)	HMK S-552	Sclerotherapy (Liquid or Microfoam)
36471	INJECTION OF SCLEROSANT; MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA), SAME LEG	HMK S-552	Sclerotherapy (Liquid or Microfoam)
36473	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; FIRST VEIN TREATED	A-1025 (CG)	Saphenous Vein Ablation, Mechanical Occlusion Chemical Ablation (MOCA)
36474	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	A-1025 (CG)	Saphenous Vein Ablation, Mechanical Occlusion Chemical Ablation (MOCA)
36475	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS RADIOFREQUENCY; FIRST VEIN TREATED	A-0174 (CG)	Saphenous Vein Ablation, Radiofrequency
36476	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	A-0174 (CG)	Saphenous Vein Ablation, Radiofrequency
36478	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; FIRST VEIN TREATED	A-0425 (CG)	Saphenous Vein Ablation, Laser
36479	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	A-0425 (CG)	Saphenous Vein Ablation, Laser
36482	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, BY TRANSCATHETER DELIVERY OF A CHEMICAL ADHESIVE (EG, CRYANOACRYLATE) REMOTE FROM THE ACCESS SITE, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS; FIRST VEIN TREATED	A-1024 (CG)	Saphenous Vein Ablation, Adhesive Injection
36483	ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, BY TRANSCATHETER DELIVERY OF A CHEMICAL ADHESIVE (EG, CRYANOACRYLATE) REMOTE FROM THE ACCESS SITE, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	A-1024 (CG)	Saphenous Vein Ablation, Adhesive Injection
37500	VASCULAR ENDOSCOPY, SURGICAL, WITH LIGATION OF PERFORATOR VEINS, SUBFASCIAL (SEPS)	HMK S-553	Subfascial endoscopic perforator surgery (SEPS)
37700	LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS	A-0171 (CG)	Sclerotherapy Plus Ligation, Saphenofemoral Junction
37718	LIGATION, DIVISION, AND STRIPPING, SHORT SAPHENOUS VEIN	A-0172 (CG)	Saphenous Vein Stripping
37722	LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW	A-0172 (CG)	Saphenous Vein Stripping
37765	STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS	A-0735 (CG)	Stab Phlebectomy
37766	STAB PHLEBECTOMY OF VARICOSE VEINS, ONE EXTREMITY; MORE THAN 20 INCISIONS	A-0735 (CG)	Stab Phlebectomy
37780	LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE)	A-0171 (CG)	Sclerotherapy Plus Ligation, Saphenofemoral Junction
37785	LIGATION, DIVISION, AND/OR EXCISION OF VARICOSE VEIN CLUSTER(S), 1 LEG	HMK S 558	Ligation, Division, and/or Excision of Varicose Vein Cluster(s)
37799	UNLISTED PROCEDURE, VASCULAR SURGERY	HMK S-557, HMK S-553	Spider Veins, Treatment, Subfascial endoscopic perforator surgery (SEPS)
76942	ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (E.G., BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION	HMK S-552	Sclerotherapy (Liquid or Microfoam)
0524T	ENDOVENOUS CATHETER DIRECTED CHEMICAL ABLATION WITH BALLOON ISOLATION OF INCOMPETENT EXTREMITY VEIN, OPEN OR PERCUTANEOUS, INCLUDING ALL VASCULAR ACCESS, CATHETER MANIPULATION, DIAGNOSTIC IMAGING, IMAGING GUIDANCE AND MONITORING	A-1025 (CG)	Saphenous Vein Ablation, Mechanical Occlusion Chemical Ablation (MOCA)
J3490	UNCLASSIFIED DRUGS	HMK S-552	Sclerotherapy (Liquid or Microfoam)
S2202	ECHOSCLEROTHERAPY	HMK S-551	Echosclerotherapy

36465	36466	36468	36470	36471	36473	36474
36475	36476	36478	36479	36482	36483	37500
37700	37718	37722	37765	37766	37780	37785
37799	76942	0524T	J3490	S2202

Related Policies

Refer to Guideline A-0171, Sclerotherapy Plus Ligation, Saphenofemoral Junction, for additional information.

Refer to Guideline A-0172, Saphenous Vein Stripping, for additional information.

Refer to Guideline A-0174, Saphenous Vein Ablation, Radiofrequency, for additional information.

Refer to Guideline A-0425, Saphenous Vein Ablation, Laser, for additional information.

Refer to Guideline A-0735, Stab Phlebectomy, for additional information.

Refer to Guideline A-1024, Saphenous Vein Ablation, Adhesive Injection, for additional information.

Refer to Guideline A-1025, Saphenous Vein Ablation, Mechanical Occlusion Chemical Ablation (MOCA), for additional information.

Refer to Medical Policy S-551, Echosclerotherapy, for additional information.

Refer to Medical Policy S-552, Sclerotherapy (Liquid or Microfoam), for additional information.

Refer to Medical Policy S-553, Subfascial endoscopic perforator surgery (SEPS), for additional information.

Refer to Medical Policy S-554, Endovenous Cryoablation, for additional information.

Refer to Medical Policy S-555, Laser Treatment, Non-Invasive, for additional information.

Refer to Medical Policy S-556, Ligation or Ablation, Incompetent Perforator Veins, for additional information.

Refer to Medical Policy S-557, Spider Veins, Treatment, for additional information.

Refer to Medical Policy S-558, Ligation, Division, and/or Excision of Varicose Vein Cluster(s), for additional information.

Refer to Medical Policy E-9, Non-Custom/Custom-Made Gradient Compression Garments/Stockings, for additional information.

Refer to Medical Policy S-100, Multiple Surgical Procedures, for additional information.

Refer to Medical Policy S-133, Endovascular/Endoluminal Stent Grafts, for additional information.

Refer to Medical Policy S-16, Assistant Surgery Eligibility Criteria, for additional information.

Refer to Medical Policy S-28, Cosmetic Surgery vs. Reconstructive Surgery, for additional information.

Refer to Provider Reimbursement Policy RP-014, Bilateral and Multiple Surgical Procedures, for additional information.

Professional Statements and Societal Positions Guidelines

American Vein and Lymphatic Society

In 2015, the AVLS(previously named the American College of Phlebology) published guidelines on the treatment of superficial vein disease.

AVLS gave a Grade 1 recommendation based on high quality evidence that compression is an effective method for the management of symptoms, but when patients have a correctable source of reflux, definitive treatment should be offered unless contraindicated. AVLS recommends against a requirement for compression therapy when a definitive treatment is available. AVLS gave a strong recommendation based on moderate quality evidence that endovenous thermal ablation is the preferred treatment for saphenous and accessory saphenous vein incompetence, and gave a weak recommendation based on moderate quality evidence that mechanochemical ablation may also be used to treat venous reflux.

In 2017, AVLS published guidelines on the treatment of refluxing accessory saphenous veins. The College gave a Grade 1 recommendation based on level C evidence that patients with symptomatic incompetence of the accessory saphenous veins be treated with endovenous thermal ablation or sclerotherapy to reduce symptomatology. The guidelines noted that although accessory saphenous veins may drain into the great saphenous vein before it drains into the common femoral vein, they can also empty directly into the common femoral vein.

National Institute for Health and Care Excellence

In 2013, the NICE updated its guidance on ultrasound-guided foam sclerotherapy for varicose veins. NICE stated that:

"1.1 Current evidence on the efficacy of ultrasound-guided foam sclerotherapy for varicose veins is adequate. The evidence on safety is adequate, and provided that patients are warned of the small but significant risks of foam embolization (see section 1.2), this procedure may be used with normal arrangements for clinical governance, consent and audit.

1.2 During the consent process, clinicians should inform patients that there are reports of temporary chest tightness, dry cough, headaches and visual disturbance, and rare but significant complications including myocardial infarction, seizures, transient ischaemic attacks and stroke."

In 2015, NICE published a technology assessment on the clinical effectiveness and cost-effectiveness of foam sclerotherapy, endovenous laser ablation, and surgery for varicose veins.

In 2016, NICE revised its guidance on endovenous mechanochemical ablation, concluding that "Current evidence on the safety and efficacy of endovenous mechanochemical ablation for varicose veins appears adequate to support the use of this procedure...."

I80.00	I80.01	I80.02	I80.03	I83.011	I83.012	I83.013
I83.014	I83.015	I83.018	I83.019	I83.021	I83.022	I83.023
I83.024	I83.025	I83.028	I83.029	I83.10	I83.11	I83.12
I83.201	I83.202	I83.203	I83.204	I83.205	I83.208	I83.209
I83.211	I83.212	I83.213	I83.214	I83.215	I83.218	I83.219
I83.221	I83.222	I83.223	I83.224	I83.225	I83.228	I83.229
I83.811	I83.812	I83.813	I83.819	I83.891	I83.892	I83.893
I83.899	I87.2	I87.9

Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Surgical treatment of varicose veins is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business

Links

Link to Provider Resource Center for the Medical Policy Update

08/2021, Surgical Treatment of Varicose Veins. Coverage Criteria Revised.

Link to References

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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.