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.
Requires prior authorization:
- Sclerotherapy - after endovenous catheter ablation of axial varicose veins AND as a stand-alone procedure.
- Note: Sclerotherapy should be requested in advance of any endovenous catheter ablation procedure if sclerotherapy is intended as adjunctive treatment to catheter ablation.
Does not require prior authorization:
- Endovenous catheter ablation procedure (VNUS or EVLA)
- Transilluminated powered phlebectomy (TriVex TIPP system)
- Vein ligation/division/stripping surgery
- Ambulatory phlebectomy (stab avulsion) or transilluminated powered phlebectomy (TriVex System)
- ClariVein® occlusion catheter system
Ambulatory phlebectomy (stab avulsion) or transilluminated powered phlebectomy (TriVex System) is covered for the same indications as sclerotherapy, either as an adjunctive treatment or primary treatment of symptomatic venous disease.
Treatment of varicose veins - with any of the techniques listed in the Definitions section - is covered per the indications listed below, unless it is specifically listed in the “not covered” section.
- Reflux at the saphenofemoral or saphenopopliteal junction (i.e., proximal to the anticipated location of sclerotherapy injections);
- Is being treated or was previously treated; and
- is documented in the ultrasound submitted with the request; and
- Varicosities are symptomatic and not merely unsightly as defined by at least one of the following:
- Ulceration secondary to venous stasis; or
- Hemorrhage from ruptured varicose vein; or
- Superficial thrombophlebitis; or
- Pain that
- Is accompanied by edema; and
- Interferes with activities of daily living; and
- Has required chronic analgesic medication; and
- Has failed physician ordered graded compression garments for a minimum of three months
- Three sessions of sclerotherapy (per leg) may be authorized for twelve months after the index (initial) procedure.
Indications that are not covered
- Laser photocoagulation (laser therapy) to treat telangectasias (spider veins) is considered cosmetic and therefore not covered.
- The treatment of spider veins/telangiectasis in the absence of associated hemorrhage.
Ambulatory phlebectomy (stab avulsion) or transilluminated powered phlebectomy (TriVex System) - used for the removal of varicose veins through multiple stab incisions. Clinical applications of phlebectomy include:
- adjunct to EVLA or VNUS, in order to eliminate symptomatic varicosities; or
- a procedure to treat primary lower extremity varicose veins.
ClariVein® is an occlusion catheter, nonthermal vein ablation system – an endovascular technique for the treatment of venous reflux disease.
Endovenous laser ablation (EVLA) - a less invasive alternative to surgical venous ligation and stripping. Laser energy is delivered via fiber-optic catheter to ablate the lumen of incompetent veins of medium to large diameter, typically at proximal sites in the lower extremities (saphenofemoral junction, saphenous popliteal junction, greater saphenous vein, or lesser saphenous vein).
Endovenous radiofrequency obliteration (commonly referred to as VNUS Closure®) - another endoluminal catheter-based technique, for the same clinical situations as EVLA. Rather than laser energy, radiofrequency energy (microwaves) is used to heat and thereby ablate the lumen of the vein.
Laser photocoagulation - is laser therapy to treat spider veins (not varicose veins).
Sclerotherapy - the injection of a sclerosing substance into a vein for the purpose of producing permanent fibrosis and occlusion of the vessel. Clinical applications of Sclerotherapy include:
- adjunct to EVLA or VNUS, in order to treat associated varicose veins or refluxing veins not amenable to ablative techniques;
- a primary procedure to treat lower extremity varicose veins or
- as a standalone treatment for axial reflux not amenable to other treatment modalities (i.e., ablation).
Vein Ligation/division/stripping surgery - the procedures above (EVLA and VNUS) have made these traditional surgical techniques for venous disease much less common.
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.
Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk
Injection of sclerosing solution; single vein
Injection of sclerosing solution; multiple veins, same leg
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated
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)
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated
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)
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)
Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions
Ligation, division, and stripping, short saphenous vein
Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below
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
Ligation of perforator veins, subfascial, radical (Linton type), with or without skin graft, open
Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions
Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions
Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure)
Ligation, division, and/or excision of varicose vein cluster(s), 1 leg
Unlisted procedure, vascular surgery
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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.
- Alguire, P. and Scovell, S. Overview and management of lower extremity chronic venous disease. In: UpToDate, Eidt, J. and Mills, J. (Ed), UpToDate, Waltham, MA. (Accessed on Feb 1, 2017.)
- 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.
- 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.
- 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.
- Hayes, Inc. Hayes Search and Summary. Stab Phlebectomy for Treatment of Varicose Veins in Adults. Lansdale, PA: Hayes, Inc. May, 2016.
- 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)
- 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).
- 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).
- Society of Vascular Surgery (2011). The care of patients with varicose veins and associated chronic venous disease: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. Journal of Vascular Surgery, 53(5) Supplement, p2S-48S