HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
S-552-001
Topic:
Sclerotherapy (Liquid or Microfoam)
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 this Medical Policy under the section of Policy Position:

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, Kusters
  • Telangiectasia/Reticular Veins: Spider Veins (considered cosmetic)

COMMON ABBREVIATIONS:

  • CFV - Common Femoral Vein: normal
  • PFV - Proximal Femoral Vin
  • 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

C2r

Recurrent varicose veins

C3

Edema

C4

Changes in skin and subcutaneous tissue secondary to cardiovascular disease (CVD)

C4a

Pigmentation and eczema

C4b

Lipodermatosclerosis or atrophie blanche

C4C

Corona phlebectatica

C5

Healed

C6

Active venous ulcer

C6r

Recurrent active venous ulcer

S

Symptomatic

A

Asymptomatic
Policy Position

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
  • Venous insufficiency symptoms causing functional impairment, including ONE (1) or more of the following:
    • Bleeding or ruptured superficial varicose veins, or 
    • Leg edema or
    • Leg fatigue; or
    • Leg pain; or
    • Persistent or recurrent superficial thrombophlebitis; or
    • Persistent or recurrent superifical venous stasis; or
    • Skin changes (e.g., lipodermatosclerosis, hemosiderosis); and
  •  At least three (3) months of failed conservative therapies including compression stockings, walking & leg elevation (Note: Conservative treatments are not necessary for the treatment of ulcers); or
  • Bleeding varicosities smaller than five (5) mm.

Note: 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.

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

Note: 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.

Note: 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.

Note: 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.

Note: 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.

 Note: 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.

Note: 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.

36465

36466

36470

36471

76942

J3490


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...."


Covered Diagnosis Codes for Procedure Codes 36465, 36466, 36470, 36471

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. 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



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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.

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.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.




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.