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Coverage criteria policies

Varicose vein procedures

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for the following treatments for varicose veins of the lower limbs:

  • Endovenous thermal ablation procedures [e.g. endovenous laser ablation (EVLA), endovenous laser therapy (EVLT), endovenous laser ablative surgery (ELAS) or endovenous radiofrequency ablation (EVRF, VNUS RF)]
  • Sclerotherapy

Prior authorization is not required for the following treatments for varicose veins of the lower limbs:

  • Ambulatory phlebectomy
  • Vein ligation/stripping
  • Subfacial endoscopic perforator surgery (SEPS)

Coverage

Treatment of symptomatic varicose veins is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

Endovenous thermal ablation procedures (e.g. EVLA, EVLT, ELAS, VNUS)

  1. Initial minimally invasive endovenous thermal ablation for treatment of the great saphenous vein (GSV) or small saphenous vein (SSV) is eligible for coverage when the following criteria are met:
    1. Results of duplex ultrasound scanning performed no more than six months prior to the requested procedure and measured in the standing position (or upright position on an ultrasound table) indicate:
      1. Reflux duration of 0.5 seconds or greater in the GSV or SSV for which treatment is requested and
      2. The diameter of the vein(s) targeted for treatment is 3mm or greater
    2. Venous reflux/insufficiency results in at least one of the following (i-iv):
      1. Venous ulceration, defined as persisting for more than three months or recurring in the same area.
      2. External hemorrhage from a ruptured superficial varicose vein (1 or more episodes in the same vein)
      3. Recurrent superficial thrombophlebitis, defined as history of 2 or more episodes in the same vein.
      4. Persistent pain that is moderate to severe in intensity and is characterized by all of the following:
        1. Limits activities of daily living
        2. Is accompanied by recurring edema (swelling)
        3. Has required chronic analgesic medication for management
        4. Has failed to respond to treatment with physician ordered graded compression garments for a minimum of three months
    3. Documentation requirements include all of the following:
      1. Duplex ultrasound report and interpretation which demonstrate location and duration of venous reflux. A narrative description alone is insufficient to meet this documentation requirement.
      2. Detailed clinical history including symptoms, medically supervised conservative treatments attempted, and response to treatments.
      3. Description of any previous invasive treatment of varicose veins.
      4. Clear description of the intended treatment plan, including applicable procedure (CPT) codes for the planned interventions. Documentation must include the name, location, size and duration of reflux for each vessel to be treated. For endovenous ablation procedures, only one primary code and one secondary code for the affected leg(s) will be considered.
  2. Treatment of accessory saphenous veins with minimally invasive endovenous thermal ablation is eligible for coverage when the following criteria are met:
    1. All of the criteria noted above in section 1 A-C are met; and
    2. Documentation and corresponding duplex ultrasound report indicate either isolated insufficiency of the accessory saphenous vein or insufficiency of the great or small saphenous veins has been successfully treated.
  3. Repeat minimally invasive endovenous thermal ablation for treatment of recurrent or persistent reflux in the great saphenous vein (GSV) or small saphenous vein (SSV) is eligible for coverage when the following criteria are met:
    1. Results of duplex ultrasound scanning performed after the initial endovenous ablation and within 6 months of the current request indicate persistent reflux duration of 0.5 seconds or greater in the GSV or SSV.
    2. Documentation must include the date of previous treatment and detailed description of persistent symptoms that limit activities of daily living. A trial of conservative therapies is not required for members with persistent or recurrent reflux in the GSV or SSV who have previously undergone endovenous catheter ablation procedures in the same leg because such therapies are unlikely to be successful in this clinical situation.

Sclerotherapy procedures

  1. Sclerotherapy of symptomatic accessory saphenous veins, perforator veins and small tributary veins completed at the same time as GSV/SSV/Accessory vein treatment (e.g. EVLA, EVLT, ELAS, VNUS) is eligible for coverage when the following criteria are met:
    1. All criteria for GSV/SSV/Accessory vein treatment are met
    2. The diameter of the vein(s) targeted for treatment is 3mm or greater
    3. Duplex ultrasound report results indicate reflux duration of 0.5 seconds or greater in the veins for which treatment is requested.
    4. Sclerotherapy is limited to a maximum of three treatment sessions per leg, per six month period. The sclerosing agent itself is included as part of the procedure and will not be reimbursed separately.
  2. Sclerotherapy as a stand-alone treatment for symptomatic accessory saphenous veins, perforator veins, and small tributary veins in a member who has previously undergone treatment of GSV/SSV/Accessory veins (e.g. endovenous ablation technique, vein ligation, or stripping), is eligible for coverage when the following criteria are met:
    1. Treatment of the saphenous vein or accessories was completed at least 3 months prior to current request
    2. Results of duplex ultrasound scanning performed no more than six months prior to the requested procedure and measured in the standing position (or upright position on an ultrasound table) indicate all of the following:
      1. Absence of reflux in the GSV or SSV
      2. The diameter of the accessory vein(s ) targeted for treatment is 3mm or greater
      3. Duplex ultrasound report indicates reflux duration of 0.5 seconds or greater in the veins for which treatment is requested.
    3. Venous reflux/insufficiency results in at least one of the following (A-D):
      1. Venous ulceration, defined as persisting for more than three months or recurring in the same area.
      2. External hemorrhage from a ruptured superficial varicose vein (1 or more episodes in the same vein)
      3. Recurrent superficial thrombophlebitis, defined as history of 2 or more episodes in the same vein.
      4. Persistent pain that is moderate to severe in intensity and is characterized by all of the following:
        1. Limits activities of daily living
        2. Is accompanied by recurring edema (swelling)
        3. Has required chronic analgesic medication for management
        4. Has failed to respond to treatment with physician ordered graded compression garments for a minimum of three months
    4. Documentation requirements include all of the following:
      1. Duplex ultrasound report and interpretation which demonstrate location and duration of venous reflux. A narrative description alone is insufficient to meet this documentation requirement.
      2. Detailed clinical history including symptoms, medically supervised conservative treatments attempted, and response to treatments.
      3. Description of previous invasive treatment of varicose veins and date(s) completed
      4. Clear description of the intended treatment plan, including applicable procedure (CPT) codes for the planned interventions. Documentation must include the name, location, size and duration of reflux for each vessel to be treated.
    5. Sclerotherapy is limited to a maximum of three treatment sessions per leg, per six month period when medical criteria are met. The sclerosing agent itself is included as part of the procedure and will not be reimbursed separately.
  3. Sclerotherapy as a stand-alone treatment for symptomatic accessory saphenous veins and small tributary veins in a member who has not previously undergone treatment of GSV/SSV/Accessory veins (e.g. endovenous ablation technique, vein ligation, or stripping) is eligible for coverage when the following criteria are met:
    1. Results of duplex ultrasound scanning performed no more than six months prior to the requested procedure and measured in the standing position(or upright position on an ultrasound table) indicate all of the following:
      1. Absence of reflux in the GSV or SSV
      2. The diameter of the accessory veins targeted for treatment is 3mm or greater
      3. Reflux duration of 0.5 seconds or greater in the veins for which treatment is requested.
    2. Venous reflux/insufficiency results in at least one of the following (A-D):
      1. Intractable venous ulceration, defined as persisting for more than three months or recurring in the same area
      2. External hemorrhage from a ruptured superficial varicose vein (1 or more episodes in the same vein)
      3. Recurrent superficial thrombophlebitis, defined as history of 2 or more episodes in the same vein.
      4. Persistent pain that is moderate to severe in intensity and is characterized by all of the following:
        1. Limits activities of daily living
        2. Is accompanied by recurring edema (swelling)
        3. Has required chronic analgesic medication for management
        4. Has failed to respond to treatment with physician ordered graded compression garments for a minimum of three months
    3. Documentation requirements include all of the following:
      1. Duplex ultrasound report and interpretation which demonstrate location and duration of venous reflux. A narrative description alone is insufficient to meet this documentation requirement.
      2. Detailed clinical history including symptoms, medically supervised conservative treatments attempted, and response to treatments.
      3. Clear description of the intended treatment plan, including applicable procedure (CPT) codes for the planned interventions. Documentation must include the name, location, size and duration of reflux for each vessel to be treated.
    4. Sclerotherapy is limited to a maximum of three treatment sessions per leg, per six month period when medical criteria are met. The sclerosing agent itself is included as part of the procedure and will not be reimbursed separately.
  4. Retreatment or subsequent sclerotherapy of symptomatic accessory saphenous veins and small tributary veins is eligible for coverage when all of the following criteria are met:
    1. Results of duplex ultrasound scanning performed no more than six months prior to the requested procedure and measured in the standing position (or upright position on an ultrasound table) indicate all of the following :
      1. Persistent or recurrent veins measuring 3mm or greater following a previously completed series of sclerotherapy.
      2. Absence of reflux proximal (higher than) the area being treated
    2. Persistent pain that is moderate to severe in intensity and is characterized by all of the following:
      1. Limits activities of daily living
      2. Is accompanied by recurring edema (swelling)
      3. Has required chronic analgesic medication for management
      4. Has failed to respond to treatment with physician ordered graded compression garments for a minimum of three months
    3. Documentation must include a clear description of the intended treatment plan, including applicable procedure (CPT) codes for the planned intervention. Documentation must include the name, location, size and duration of reflux for each vessel to be treated and the number of treatment sessions clinically indicated.
    4. Sclerotherapy is limited to a maximum of three treatment sessions per leg, per six month period when medical criteria are met. The sclerosing agent itself is included as part of the procedure and will not be reimbursed separately.
  5. Sclerotherapy for treatment of symptomatic vulvar varices is eligible for coverage when all of the following criteria are met:
    1. Documentation indicates persistent vulvar discomfort, swelling and pressure that are aggravated by prolonged standing, exercise, or sexual intercourse.
    2. Member is not currently pregnant or is greater than 12 weeks post-partum.
    3. Results of duplex ultrasound scanning performed no more than six months prior to the requested procedure and measured in the standing position indicate the absence of saphenous vein reflux on the affected side or saphenous vein reflux has been treated, but painful vulvar varicosities persist.
    4. Sclerotherapy is limited to a maximum of three treatment sessions per six month period. The sclerosing agent itself is included as part of the procedure and will not be reimbursed separately.

Indications that are not covered

  1. Medical adhesive, also known as cyanoacrylate or n-butyl-cyanoacrylate (e.g. VenaSeal Closure System) is considered investigational.
  2. Sclerotherapy of the great or small saphenous vein is considered investigational
  3. Treatment of varicose veins less than 3mm in diameter (including telangiectasia or spider veins), via any method, in the absence of associated hemorrhage is considered cosmetic.

Definitions

Ambulatory phlebectomy or transilluminated powered phlebectomy (TriVex System) – removes segments of varicose veins through multiple stab incisions.

ClariVein® is non-thermal vein ablation system. The device consists of a flexible, steerable infusion catheter with a 360 degree, rotating dispersion wire. The wire tip causes minimal mechanical damage to the vein wall and the rotating tip evenly distributes a sclerosing agent to the targeted treatment area. .

Duplex ultrasound combines traditional ultrasound, which uses sound waves that bounce off blood vessels to create pictures, with Doppler ultrasound, which records sound waves reflecting off moving objects such as blood, to detect flow, direction of flow and speed of flow through vessels.

Endovenous thermal ablation procedures (e.g. EVLA, EVLT, ELAS, VNUS) are less invasive alternatives to surgical venous ligation and stripping of the GSV or SSV. A catheter is inserted into the affected vein through a small incision, usually near the knee, and advanced. After proper placement is confirmed via Duplex ultrasound imaging, the radiofrequency electrode or laser is slowly withdrawn while applying energy to occlude the vein.

Laser photocoagulation - is laser therapy to telangiectases (spider veins).

Medical Tissue Adhesive (Cyanocrylate, VariClose or VenaSeal Closure System) is a minimally invasive, non-thermal, non-sclerosant procedure that uses a medical adhesive to close a symptomatic varicose vein.

Sclerotherapy is the injection of an inflammatory chemical solution (sclerosing agent) directly into a vein. The sclerosant causes irritation and damage to the lining of the of the vein wall. As a result, the vein hardens or scleroses. This sclerosed vein is eventually absorbed into the body. Following sclerotherapy, the remaining vessels in the venous system compensate for the absent or treated vein.

Telangiectases are permanently dilated blood vessels, also called spider veins, which create fine red or blue lines on the skin.

The venous system of the lower extremities consists of two main components; the deep venous and the superficial venous system. The two system are connected by perforator veins. The deep venous system contains the popliteal and femoral veins. The superficial venous system contains the greater saphenous vein (GSV) and the short saphenous vein (SSV). The GSV meets the femoral vein at the saphenofemoral junction (SFJ). The SSV meets the deep venous system and the saphenopopliteal junction (SPJ).

Varicose Veins (also known as varices or varicosities) are defined as dilated, tortuous subcutaneous veins that are greater than or equal to 3mm in diameter measured in the upright position. They develop as result of weakening or incompetent of a one-way valve.

Vein Ligation/division/stripping surgery - the procedures above (EVLA and VNUS) have made these traditional surgical techniques for venous disease much less common.

Venous insufficiency or reflux occurs when an incompetent valve allows blood to leak backwards through the valve. This causes increased venous pressure and capillary damage which is typically worse at the more distal (lower) part of the vein. Symptoms resulting from venous insufficiency may include pain, cramping, burning, throbbing, swelling, and feelings of heaviness or fatigue in the legs.

Vulvar varices (varicosities) are enlarged, distended veins that appear as fold in the vaginal mucosa or labia or as a grape-like cluster of veins in female genital area

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

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)

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

36468

Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk

36470

Injection of sclerosing solution; single vein

36471

Injection of sclerosing solution; multiple veins, same leg

36473

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated

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)

36475

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated

36476

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

36478

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated

36479

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

36482

Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated

36483

Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) 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)

37241

Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)

37700

Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions

37718

Ligation, division, and stripping, short saphenous vein

37722

Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below

37735

Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer and skin graft and/or interruption of communicating veins of lower leg, with excision of deep fascia

37760

Ligation of perforator veins, subfascial, radical (Linton type), with or without skin graft, open

37765

Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions

37766

Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions

37780

Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure)

37785

Ligation, division, and/or excision of varicose vein cluster(s), 1 leg

37799

Unlisted procedure, vascular surgery

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Alguire, P and Mathes, B. Medical Management of lower extremity chronic venous disease. In: UpToDate, Eidt, J. and Mills, J. (Ed), UpToDate, Waltham, MA. (Accessed on March 5, 2018).
  2. Coleridge-Smith, P. (2009) Leg Ulcer Treatment. Journal of Vascular Surgery. 2009: 49(3); 804-808
  3. Gloviczki, P., Comerota, A. J., Dalsing, M. C., Eklof, B. G., Gillespie, D. L., Gloviczki, M. L., ... & Padberg, F. T. (2011). The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. Journal of vascular surgery, 53(5), 2S-48S.
  4. Hayes, Inc. Hayes Health Technology Brief. Polidocanol Endovenous Microfoam (varithena) 1% for Treatment of Varicose Veins. Lansdale, PA: Hayes, Inc.; May, 2016
  5. Hayes, Inc. Hayes health Technology Brief. Endovenous Mechanochemical Ablation (MOCA) (ClariVein Infusion Catheter, Nonthermal Vein Ablation System; Vascular Insights LLC) for Treatment of Varicose Veins. Lansdale, PA: Hayes, Inc.; June, 2017
  6. Hayes, Inc. Hayes Health Technology Brief. Ultrasound-Guided Foam Sclerotherapy (UGFS) for Varicose Veins. Lansdale, PA: Hayes, Inc.; Nov.2011. Reviewed Dec, 2013/Archived Dec, 2014.
  7. Hayes, Inc. Hayes Medical Technology Directory Report. Transilluminated Powered Phlebectomy for Symptomatic Varicose Veins. Lansdale, PA: Hayes, Inc.; May, 2002. Reviewed April, 2007/Archived Jan, 2008.
  8. Hayes, Inc. Hayes Medical Technology Directory Report. Endovenous Laser Therapy for Varicose Veins due to Great Saphenous Vein Reflux. Lansdale, PA: Hayes, Inc.; Feb, 2009. Reviewed Feb, 2013/Archived Mar, 2014.
  9. Hayes, Inc. Hayes Medical Technology Directory Report. Endovenous Laser Therapy for Varicose Veins due to Small Saphenous Vein Reflux. Lansdale, PA: Hayes, Inc.; Mar, 2009. Reviewed Feb, 2013/ Archived Apr, 2014.
  10. Hayes, Inc. Hayes Medical Technology Directory Report. Comparative Effectiveness of Endovenous Laser Therapy Versus Conventional Surgery for Symptomatic Varicose Veins: A Review of Reviews. Lansdale, PA: Hayes, Inc.; Sept, 2017.
  11. Hayes, Inc. Hayes Medical Technology Directory Report. Endovenous Radiofrequency Ablation Versus Conventional Surgery for Symptomatic Varicose Veins: A Review of Reviews. Lansdale, PA: Hayes, Inc.; Oct, 2017.
  12. Hayes, Inc. Hayes Search and Summary. Stab Phlebectomy for Treatment of Varicose Veins in Adults. Lansdale, PA: Hayes, Inc. May, 2016.
  13. Johnson, N. Vulvovaginal varicosities and pelvic congestion syndrome. In: UpToDate, Barbieri, R. , Eidt, J., Mills, and Levine, D.(Ed), UpToDate, Waltham, MA. (Accessed on March, 29, 2018).
  14. Kuyumcu, G., Salazar, G., Prabhakar, A. and Ganguli, S. (2016). Minimally invasive treatments for perforator vein insufficiency. Cardiovascular Diagnosis & Therapy. 2016 Dec; 6(6): 593-598.
  15. Lhnat, D. Endovenous laser ablation for the treatment of lower extremity chronic venous disease. In: UpToDate, Mills, J. and Eidt, J. (Ed), UpToDate, Waltham, MA. (Accessed on Feb, 1, 2017)
  16. Meissner, M. H. (2009). Pathophysiology of varicose veins and chronic venous insufficiency. In Comprehensive Vascular and Endovascular Surgery. Elsevier.
  17. National Clinical Guideline Centre. (2013) Varicose veins in the legs. The diagnosis and management of varicose veins. London (UK): National Institute for Health and Care Excellence (NICE); 2013 Jul 23p. (Clinical guideline; no 168).
  18. Ombrellino, M. and Kabnick, L. (2005). Varicose Vein Surgery. Seminars in Interventional Radiology. 2005 Sep; 22(3): 185-194.
  19. Scovell, S. Liquid, foam and glue sclerotherapy techniques for the treatment of lower extremity veins. In: UpToDate, Eidt, J., Mills, J. Dover, J. (Ed), UpToDate, Waltham, MA. (Accessed on Feb, 1, 2017).
  20. Scovell, S. Phlebitis and thrombosis of the superficial lower extremity veins. In: UpToDate, Eidt, J. and Mills, J. (Ed), UpToDate, Waltham, MA. (Accessed on March 19, 2018).
  21. Scovell, S. Radiofrequency ablation for the treatment of lower extremity chronic venous disease. In: UpToDate, Eidt, J. and Mills, J. (Ed), UpToDate, Waltham, MA. (Accessed on March 19, 2018).
  22. Word, R. (2010). Medical and Surgical Therapy for Advanced Chronic Venous Insufficiency. The Surgical Clinics of North America. 2010 Dec; 90(6): 1195-1214.

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Policy activity

  • 03/01/2000 - Date of origin
  • 08/01/2018 - Effective date
Review date
  • 01/2018
Revision date
  • 05/08/2018

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