Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence

Policy #:11.02.01r

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

TREATMENTS OF VARICOSE VEINS OF THE LOWER EXTREMITIES AND PERFORATOR VEIN INCOMPETENCE

Note:
This table shows the relationship of specific varicose vein types (column) with the potential treatments (row) indicated by a gray highlighted box. Medically Necessary criteria for these treatments of varicose veins of the lower extremities and perforator vein incompetence is described in the Policy Section of this document.
Stripping and LigationEndovenous Radio-
frequency Ablation
(EFRA)
Endovenous Laser Ablation Therapy (EVLT)SclerotherapyAmbulatory Phlebectomy/Stab PhlebectomyTransilluminated-
Powered
Phlebectomy
(TIPP)
Subfacial Endoscopic Perforator Vein Surgery (SEPS)
Greater or Lesser Saphenous Veins
Duplicate Greater Saphenous Veins
Accessory Saphenous Veins
Symptomatic Varicose Tributaries
Perforator
Veins


MEDICALLY NECESSARY

GREATER OR LESSER SAPHENOUS VEINS
Stripping and Ligation, Endovenous Radiofrequency Ablation (ERFA), or Endovenous Laser Ablation Therapy (EVLT)

The treatment of symptomatic greater or lesser saphenous varicose veins/chronic venous insufficiency by stripping and ligation, endovenous radiofrequency ablation (ERFA), or endovenous laser ablation therapy (EVLT), is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • Documented evidence of one or more of the following symptomatic conditions:
    • Non-healing ulceration secondary to venous stasis adjacent to an identified incompetent varicosity of truncal or perforator vein
    • Recurrent superficial thrombophlebitis in dilated incompetent veins or clusters
    • Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity requiring at least one of the following:
      • Medical or surgical intervention
      • Compensation for blood loss anemia
      • Documented aneurysmal formation with skin and vein wall fusion (pre-rupture)
    • Persistent pain, swelling, itching, burning, or other symptoms are associated with saphenous reflux and the symptoms significantly interfere with activities of daily living (e.g., mobility).
  • A documented three-month trial of conservative medical management, including the use of graduated, elastic compression stockings* (with instructions on their use), mild exercise, periodic leg elevation, avoidance of long periods of standing, weight reduction as appropriate, and analgesia for symptom relief, has failed in managing (or controlling) symptoms.
    • Compression stockings are defined as graduated elasticized compression stockings. Use of non-graduated compression garments such as support pantyhose does not fulfill this requirement. Lack of compliance with compression stockings does not support the need for intervention without documentation of other failed conservative treatments as well.
      *Note: Refer to the applicable medical policy that addresses coverage criteria for compression stockings. Three-month trial of conservative medical management is not required for individuals with Clinical, Etiology, Anatomy, Pathophysiology (CEAP) C5 or C6 (See guidelines section).
  • Assessment of the lower extremity venous system by duplex studies that show the anatomy, size, and tortuosity of the greater and lesser saphenous vein, within the last six months. These studies must demonstrate ALL of the following:
    • Presence and patency of the deep venous system
    • Absence of large chronic thrombosis
    • Greater and/or lesser saphenous vein incompetence/reflux (i.e., reflux greater than 0.5 second duration) that correlates with the individual's symptoms
    • Greater and/or lesser saphenous vein diameters
      • Greater saphenous vein diameter is 5 mm to 20 mm (unless documented by the supplier of the device to exceed 20 mm)
      • Lesser saphenous vein diameter is 4 mm to 20 mm (unless documented by the supplier of the device to exceed 20 mm)
  • There is absence of clinically significant or symptomatic peripheral arterial insufficiency in the region of the treatment.
  • There is no planned treatment of incompetent valves or risk of direct injury to perforator veins of the calf that may induce thrombus propagation into the deep vein system.
  • ERFA or EVLT for the treatment of symptomatic greater or lesser saphenous veins, ALL of the following criteria must also be met:
    • The anatomy is amenable to one of these procedures and there is absence of vein tortuosity that would impair catheter advancement and distance separation from skin as to preclude thermal injury
    • The saphenous vein(s) are nonaneurysmal.
    • ERFA, EVLT for the treatment of the greater saphenous vein must include the portion above and below the knee. This is part of the planned surgery, and therefore ablation of portion above and below the knee is not eligible for separate payment.

Repeat Treatments

Repeat procedures of the greater or lesser saphenous vein are considered medically necessary and, therefore, covered, when, in addition to the above criteria, a repeat duplex study has been performed since the last procedure and demonstrates saphenous reflux.

DUPLICATE GREATER SAPHENOUS VEINS
Stripping and Ligation, ERFA, or EVLT

Stripping and ligation, ERFA, or EVLT of symptomatic duplicate greater saphenous varicose veins/chronic venous insufficiency is considered medically necessary and, therefore, covered when ALL of the above criteria for greater saphenous veins are met.

ACCESSORY SAPHENOUS VEINS
Stripping and Ligation, ERFA, EVLT, Ambulatory Phlebectomy/Stab Phlebectomy, or Sclerotherapy

The treatment of symptomatic accessory saphenous varicose veins/chronic venous insufficiency by stripping and ligation, ERFA, EVLT, ambulatory phlebectomy/stab phlebectomy, or sclerotherapy with injectable liquid or microfoam followed by compression is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • One of the following procedures is performed:
    • Stripping and ligation, or sclerotherapy with injectable liquid or microfoam followed by compression for the treatment of accessory saphenous veins, when incompetence of the accessory saphenous vein is isolated or the greater or lesser saphenous veins have been previously eliminated for at least three months.
    • Ambulatory phlebectomy/stab phlebectomy for the treatment of accessory saphenous veins, is performed with or without previous elimination of the greater or lesser saphenous veins.
    • ERFA or EVLT, for the treatment of accessory saphenous veins, when ALL of the following criteria are met:
      • The accessory saphenous vein diameter is 5mm or greater
      • The anatomy is amenable to one of these procedures and there is absence of vein tortuosity that would impair catheter advancement and distance separation from skin as to preclude thermal injury.
      • The accessory saphenous vein(s) are nonaneurysmal.
      • Incompetence of the accessory saphenous vein is isolated or the greater or lesser saphenous veins have been previously eliminated for at least three months.
  • Documented evidence of one or more of the following symptomatic conditions:
    • Non-healing ulceration secondary to venous stasis adjacent to an identified incompetent varicosity
    • Recurrent superficial thrombophlebitis in dilated incompetent veins or clusters
    • Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity requiring at least one of the following:
      • Medical or surgical intervention
      • Compensation for blood loss anemia
      • Documented aneurysmal formation with skin and vein wall fusion (i.e., pre-rupture)
    • Persistent pain, swelling, itching, burning, or other symptoms are associated with saphenous reflux and the symptoms significantly interfere with activities of daily living (e.g., mobility).
  • A documented three-month trial of conservative medical management, including the use of graduated, elastic compression stockings* (with instructions on their use), mild exercise, periodic leg elevation, avoidance of long periods of standing, weight reduction as appropriate, and analgesia for symptom relief, has failed in managing (or controlling) symptoms.
    • Compression stockings are defined as graduated elasticized compression stockings. Use of non-graduated compression garments such as support pantyhose does not fulfill this requirement. Lack of compliance with compression stockings does not support the need for intervention without documentation of other failed conservative treatments as well.
      *Note: Refer to the applicable medical policy that addresses coverage criteria for compression stockings. Three-month trial of conservative medical management is not required for individuals with Clinical, Etiology, Anatomy, Pathophysiology (CEAP) C5 or C6 (See guidelines section).
  • Assessment of lower extremity venous system by duplex ultrasound studies that show the anatomy, size, and tortuosity of the accessory saphenous vein within the last six months. These studies must demonstrate ALL of the following:
    • Presence and patency of the deep venous system
    • Absence of large chronic thrombosis
    • Accessory saphenous vein incompetence/reflux (i.e., reflux greater than 0.5 second duration)
      that correlates with the individual's symptoms
    • For Injectable liquid or microfoam sclerotherapy followed by compression, the accessory saphenous vein must be 3- 6 mm in diameter.
    • For ambulatory or stab phlebectomy, the accessory saphenous vein must be greater than 6 mm in diameter.
  • There is absence of clinically significant or symptomatic peripheral arterial insufficiency in the region of the treatment.
  • There is no planned treatment of incompetent valves or risk of direct injury to perforator veins of the calf that may induce thrombus propagation into the deep vein system.

Repeat Treatments

Repeat procedures of the accessory saphenous veins, are considered medically necessary and, therefore, covered, when, in addition to the above criteria, a repeat duplex study has been performed since the last procedure and demonstrates accessory saphenous reflux.

SAPHENOFEMORAL JUNCTION OR SAPHENOPOPLITEAL JUNCTION
Stripping and ligation with sclerotherapy

Stripping and ligation is considered medically necessary and, therefore, covered in combination with sclerotherapy with injectable liquid or foam and compression for ligation of the saphenofemoral junction or the saphenopopliteal junction, to treat large varicose veins or clusters not amenable to sclerotherapy or endovenous obliteration techniques.

SYMPTOMATIC VARICOSE TRIBUTARIES
The following treatments are considered medically necessary for the treatment of symptomatic varicose tributaries when performed either in conjunction with another procedure or following prior treatment (i.e., stripping and ligation, ERFA, EVLT) of the greater or lesser saphenous veins or accessory saphenous veins.

Ambulatory Phlebectomy/Stab Phlebectomy or Transilluminated-Powered Phlebectomy (TIPP)

In Conjunction with Another Procedure
Ambulatory phlebectomy/stab phlebectomy or transilluminated-powered phlebectomy (TIPP) are considered medically necessary and, therefore, covered for the treatment of symptomatic varicose tributaries when performed at the same time as another medically necessary procedure (i.e., stripping and ligation, EFRA, EVLT) of the greater or lesser saphenous veins or accessory saphenous veins.

Stand-Alone Following Prior Treatment
Ambulatory phlebectomy/stab phlebectomy or TIPP is considered medically necessary and, therefore, covered as a stand-alone procedure, for the treatment of symptomatic varicose tributaries when performed following a medically necessary procedure (i.e., stripping and ligation, ERFA, EVLT) of the greater or lesser saphenous veins or accessory saphenous veins, when ALL of the following criteria are met:
  • Documented evidence of one or more of the following symptomatic conditions:
    • Non-healing ulceration secondary to venous stasis adjacent to an identified incompetent varicosity
    • Recurrent superficial thrombophlebitis in dilated incompetent veins or clusters
    • Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity requiring at least one of the following:
      • Medical or surgical intervention
      • Compensation for blood loss anemia
      • Documented aneurysmal formation with skin and vein wall fusion (pre-rupture)
    • Persistent pain, swelling, itching, burning, or other symptoms are associated with saphenous reflux and the symptoms significantly interfere with activities of daily living (e.g., mobility).
  • A documented three-month trial of conservative medical management, including the use of graduated, elastic compression stockings* (with instructions on their use), mild exercise, periodic leg elevation, avoidance of long periods of standing, weight reduction as appropriate, and analgesia for symptom relief, has failed in managing (or controlling) symptoms.
    • Compression stockings are defined as graduated elasticized compression stockings. Use of non-graduated compression garments such as support pantyhose does not fulfill this requirement. Lack of compliance with compression stockings does not support the need for intervention without documentation of other failed conservative treatments as well.
    *Note: Refer to the applicable medical policy that addresses coverage criteria for compression stockings. Three month trial of conservative medical management is not required for individuals with Clinical, Etiology, Anatomy, Pathophysiology (CEAP) C5 or C6 (See guidelines section).
  • At the time of request for this stand-alone procedure, results of a repeat duplex-ultrasound must be provided to the Company. This duplex study must be performed since the last procedure. Results must confirm significant reflux and the size of symptomatic branch of greater saphenous vein.
  • At least two weeks have elapsed since the initial procedure (i.e., stripping and ligation, EVRA, EVLT) was performed for the treatment of the greater or lesser saphenous veins or accessory saphenous veins.
  • There is absence of clinically significant or symptomatic peripheral arterial insufficiency in the region of the treatment.
  • There is no planned treatment of incompetent valves or risk of direct injury to perforator veins of the calf that may induce thrombus propagation into the deep vein system.

Sclerotherapy

In Conjunction with Another Procedure
Sclerotherapy with injectable liquid or microfoam followed by compression is considered medically necessary and, therefore, covered for up to three treatment sessions per leg, for the treatment of symptomatic varicose tributaries 3-6 mm in diameter when performed at the same time as another medically necessary procedure (i.e., stripping and ligation, ERFA, EVLT) of the greater or lesser saphenous veins or accessory saphenous veins.

Stand-Alone Following Prior Treatment
Sclerotherapy with injectable liquid or microfoam followed by compression is considered medically necessary and, therefore, covered as a stand-alone procedure for up to three treatment sessions per leg, for the treatment of symptomatic varicose tributaries when performed following a medically necessary procedure (i.e., stripping and ligation, ERFA, EVLT) of the greater or lesser saphenous veins or accessory saphenous veins, when ALL of the following criteria are met:
  • Documented evidence of one or more of the following symptomatic conditions:
    • Non-healing ulceration secondary to venous stasis adjacent to an identified incompetent varicosity
    • Recurrent superficial thrombophlebitis in dilated incompetent veins or clusters
    • Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity requiring at least one of the following:
      • Medical or surgical intervention
      • Compensation for blood loss anemia
      • Documented aneurysmal formation with skin and vein wall fusion (i.e., pre-rupture)
    • Persistent pain, swelling, itching, burning, or other symptoms are associated with saphenous reflux and the symptoms significantly interfere with activities of daily living (e.g., mobility).
  • A documented three-month trial of conservative medical management, including the use of graduated, elastic compression stockings* (with instructions on their use), mild exercise, periodic leg elevation, avoidance of long periods of standing, weight reduction as appropriate, and analgesia for symptom relief, has failed in managing (or controlling) symptoms.
    • Compression stockings are defined as graduated elasticized compression stockings. Use of non-graduated compression garments such as support pantyhose does not fulfill this requirement. Lack of compliance with compression stockings does not support the need for intervention without documentation of other failed conservative treatments as well.
      *Note: Refer to the applicable medical policy that addresses coverage criteria for compression stockings. Three-month trial of conservative medical management is not required for individuals with Clinical, Etiology, Anatomy, Pathophysiology (CEAP) C5 or C6 (See guidelines section).
  • At the time of request for this stand-alone procedure, results of a repeat duplex-ultrasound must be provided to the Company. This duplex study must be performed since the last procedure. Results must confirm the size of varicosities (i.e., 3-6 mm in diameter).
  • At least two weeks have elapsed since the initial procedure (i.e., stripping and ligation, ERFA, EVLT) was performed for the treatment of the greater or lesser saphenous veins or accessory saphenous veins.
  • There is absence of clinically significant or symptomatic peripheral arterial insufficiency in the region of the treatment.
  • There is no planned treatment of incompetent valves or risk of direct injury to perforator veins of the calf that may induce thrombus propagation into the deep vein system.

Repeat Treatments

Repeat procedures of the symptomatic varicose tributaries are considered medically necessary and, therefore, covered, when, in addition to the above criteria, a repeat duplex study has been performed since the last procedure and demonstrates tributary reflux.

For persistent symptoms, treatment sessions beyond three treatment sessions per leg requires review by the Company with consideration given to all of all of the above stand-alone criteria for sclerotherapy are met. An additional duplex ultrasound study and review by the Company are required:
  • Duplex studies and/or color photographs of the affected area(s) of the lower extremity confirming size of the varicosities are 3-6 mm in diameter have been taken since the last treatment session.

PERFORATOR VEINS
Subfascial Endoscopic Perforator Vein Surgery (SEPS), ERFA, EVLT, or Sclerotherapy

Surgical treatment of perforator vein incompetence, including subfascial endoscopic perforator vein surgery (SEPS), ERFA, EVLT, or sclerotherapy is considered medically necessary and, therefore, covered, as a treatment of leg ulcers associated with chronic venous insufficiency when ALL of the following criteria are met:
  • Duplex ultrasound studies of the venous system demonstrate perforator vein reflux (i.e., reflux greater than 0.5 second duration) that correlates with the individual's symptoms.
  • The superficial saphenous veins (greater, lesser, or accessory saphenous and symptomatic varicose tributaries) have been previously eliminated.
  • Non-healing ulceration following combined superficial vein treatment and three months of compression therapy.
  • The venous insufficiency is not secondary to large chronic thromboembolism.

EXPERIMENTAL INVESTIGATIONAL

EFRA AND EVLT OF TRIBUTARY VEINS
EFRA and EVLT of tributary veins are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of these services cannot be established by review of the available published peer-reviewed literature.

AMBULATORY PHLEBECTOMY/STAB PHLEBECTOMY, OR TIPP OF PERFORATOR, GREATER SAPHENOUS OR LESSER SAPHENOUS VEINS
Ambulatory phlebectomy/stab phlebectomy or TIPP of perforator, greater or lesser saphenous veins are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of these services cannot be established by review of the available published peer-reviewed literature.

SCLEROTHERAPY OF ISOLATED TRIBUTARY VEINS
Sclerotherapy of isolated tributary veins without prior or concurrent treatment of saphenous veins is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

SURGICAL TREATMENT OF PERFORATOR VEIN INCOMPETENCE
Surgical treatment of perforator vein incompetence, including SEPS for the treatment of post-thrombotic syndrome of varicose veins is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

ENDOVENOUS MECHANOCHEMICAL ABLATION OF ANY VEIN
Endovenous mechanochemical ablation (e.g., ClariVein® Infusion Catheter) of any vein is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

CYANOACRYLATE ADHESIVE OF ANY VEIN
Endovascular embolization with a cyanoacrylate adhesive (e.g., VenaSeal® Closure System) is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of available published peer-reviewed literature.

ENDOVENOUS CRYOABLATION OF ANY VEIN
Endovenous cryoablation of any vein is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of available published peer-reviewed literature.

NOT MEDICALLY NECESSARY

If the criteria for the above procedures are not met, the procedures are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the treatment of illness or injury. In addition, the following applies:

EVRA or EVLT
Under most circumstances, EVRA or EVLT of the same vein performed as multiple-stage procedures is not medically necessary. In rare circumstances, multiple-stage procedures using EVRA or EVLT of the same vein may be considered medically necessary. An additional duplex ultrasound study and review by the Company are required.

Under most circumstances, repeat procedures of EVRA or EVLT are not medically necessary. In rare circumstances, recanalization of a tributary vein treated with EVRA or EVLT may occur and therefore may be considered medically necessary. In these circumstances, an additional duplex ultrasound study and review by the Company are required.

Under most circumstances, EVRA or EVLT of an accessory saphenous vein following EVRA or EVLT of greater or lesser sapheous vein are not medically necessary. In rare circumstances, EVRA or EVLT of an accessory saphenous vein following EVRA or EVLT of greater saphenous vein may be considered medically necessary. In these circumstances, an additional duplex ultrasound study and review by the Company are required.

Under most circumstances, EVRA or EVLT of tributaries following treatment of GSV and/or SSV within three months is not medically necessary. In rare circumstances, EVRA or EVLT of tributaries following treatment of GSV and/or SSV within three months may be considered medically necessary. In these circumstances, an additional duplex ultrasound study and review by the Company are required.

SCLEROTHERAPY
Sclerotherapy with injectable liquid or microfoam followed by compression is considered not medically necessary for treatment of large veins greater than 6 mm diameter or for greater or lesser saphenous veins.

ECHOSCLEROTHERAPY
Because ultrasound-monitored or duplex-guided techniques for sclerotherapy injectable liquid or microfoam followed by compression of varicose veins (echosclerotherapy) have not been shown to definitively increase the effectiveness or safety of this procedure, echosclerotherapy is considered not medically necessary and, therefore, not covered for the treatment of varicose veins of the lower extremities.

COSMETIC

TREATMENT OF ASYMPTOMATIC VARICOSE VEINS
The treatment of asymptomatic varicose veins of the lower extremities using the procedures described above are not covered by the Company because they are a cosmetic service. In addition, any sclerosing agent used in the treatment of asymptomatic varicose veins of the lower extremities is also considered cosmetic. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

TREATMENT OF TELANGIECTASIA (SPIDER VEINS)
The treatment of telangiectasia (spider veins) which does not meet the policy criteria above is not covered by the Company because it is a cosmetic service. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

Sclerotherapy

Treatment of telangiectasia (spider veins) by sclerotherapy with injectable liquid or microfoam followed by compression is not covered by the Company because it is considered a cosmetic service. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

However, requests for treatment of telangiectasia (spider veins) by sclerotherapy with injectable liquid or microfoam followed by compression are considered medically necessary, and therefore, covered on an individual basis only if there is associated hemorrhage from ruptured superficial varicosity requiring at least one of the following:
  • Medical or surgical intervention
  • Compensation for blood loss anemia
  • Documented aneurysmal formation with skin and vein wall fusion (i.e., pre-rupture)

TRAINING AND CERTIFICATION REQUIREMENTS

Refer to the Professional Provider Credentialing requirements located on the Company’s website for information on vein centers accreditation for participation in our network.

REQUIRED DOCUMENTATION
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The individual's medical record must document the following:
  • Clear and definitive history and physical that describes the symptoms and physical characteristics of varicose veins
  • Description of and failure of an adequate trial of conservative treatment (documentation must show at least a three-month trial and documented patient compliance)
  • Exclusion of other causes of edema, ulceration, and pain in the limbs and description of clinical steps taken to exclude same
  • Performance of and results of appropriate tests (including required ultrasonic examination) to confirm the presence and location of incompetent perforating veins

All requests for the treatment of varicose veins or perforator vein incompetence require review by the Company.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, treatment of varicose veins of the lower extremities and perforator vein incompetence is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in the medical policy are met.

Services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

Services that are experimental/investigational or cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

CLINICAL-ETIOLOGY-ANATOMY-PATHOPHYSIOLOGY (CEAP) CLASSIFICATION

The C component of CEAP is the clinical signs. The visible signs of chronic venous disorders are categorized as C0 to C6 depending on the appearance and are defined as:
    C0: No visible or palpable signs of venous disease
    C1: Telangiectasias/reticular veins
    C2: Varicose veins
    C3: Edema
    C4a: Pigmentation or eczema
    C4b: Lipodermatosclerosis
    or athrophie blanche
    C5: Healed venous ulcer
    C6: Active venous ulcer

US FOOD AND DRUG ADMINISTRATION (FDA)

The FDA approved the marketing of the VNUS Closure® System in March 1999; since 2002, various other laser systems (e.g., Diomed 810-nm Surgical Laser) have also been approved.

In October 2003, the FDA approved the marketing of the Smith & Nephew TriVex System, which is indicated for use in ambulatory phlebectomy procedures for the resection and ablation of varicose veins.

In March 2008, the FDA approved the marketing of the Vascular Insights ClariVein Infusion Catheter, which is indicated for use in the infusion of specified agents in the peripheral vasculature.

Subfascial endoscopic perforator surgery (SEPS) as a procedure is not regulated by the FDA. However, the FDA has approved several devices for use in a variety of minimally invasive procedures (such as SEPS) to facilitate grasping, mobilization, dissection, and transaction of tissue.

There are numerous products approved by the FDA as sclerosing agents. For example, sodium tetradecyl sulfate (Sotradecol®), which was approved by the FDA in 2004 to treat small uncomplicated varicose veins of the lower extremities that show simple dilation with competent valves and polidocanol (Asclera®), was approved by the FDA in 2010 as a sclerosing agent indicated to treat uncomplicated spider veins (varicose veins 1mm or less in diameter) and uncomplicated reticular veins (varicose veins 1mm to 3mm in diameter).

VenaSeal® Closure System was approved by the FDA on February 20, 2015 for for the permanent closure of lower extremity superficial truncal veins, such as the great saphenous vein (GSV), through endovascular embolization with coaptation.

BILLING GUIDELINES

Conservative medical management, including, but not limited to, weight reduction programs and support hose may be a benefit contract exclusion. Individual benefits must be verified.

Description

VARICOSE VEINS OF THE LOWER EXTREMITIES

The venous system of the lower extremities consists of deep and superficial veins. The deep venous system consists of the popliteal and femoral veins. The superficial venous system consists of greater and lesser saphenous veins, accessory veins, rare variant duplicate greater saphenous veins (veins that travel in parallel with the greater and lesser saphenous veins). Perforator veins cross through the fascia and connect these deep and superficial systems. One-way valves are present at the junction between the bifurcation point of the two systems (i.e., the saphenofemoral and the saphenopopliteal junction). Varicose veins are dilated, tortuous, superficial vessels that result from defective valves within the saphenous veins, from intrinsic weakness of the vein wall, from high intraluminal pressure, or, on rare occasions, from arteriovenous fistulas. Varicose veins of the lower extremities protrude from the skin surface in a rope-like manner.

Many varicose veins are asymptomatic. However, when present, symptoms of varicose veins of the lower extremities include pain, aching, burning, cramping, itching, and/or swelling. Varicose veins of the lower extremities may be complicated by peripheral edema due to venous insufficiency, hemorrhage, or thrombophlebitis. Additional complications may include venous ulceration, chronic skin ulceration, and skin changes.

The term "varicose veins" does not include telangiectatic dermal vessels (e.g., "spider veins" or "broken blood vessels"). Spider veins (also known as telangiectases) have a web-like appearance on the surface of the skin. The primary difference between spider veins and varicose veins is that spider veins lack varicose vein symptomatology. Treatment of these superficial veins is usually provided for cosmetic reasons. Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function.

Varicose veins are initially treated by conservative medical methods such as graduated, elastic compression stockings, mild exercise, periodic leg elevation, avoidance of long periods of standing, weight loss as appropriate, and analgesia for symptom relief. Additional treatment options may include stripping and ligation, endovenous radiofrequency ablation (ERFA), endovenous laser ablation therapy (EVLT), stab phlebectomy, sclerotherapy, transilluminated powered phlebectomy (TIPP), and subfascial endoscopic perforator surgery (SEPS).

CEAP CLASSIFICATION
Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification of lower extremity chronic venous disorders has been developed to serve as a basis for standardized reporting. It classifies lower extremity venous disease based upon clinical signs, etiology, anatomic location, and pathophysiologic abnormality.

The visible signs of chronic venous disorders are categorized as a class 0 (no visible sign of disease) to class 6 (active ulceration).

TREATMENT OF VARICOSE VEINS
Stripping and Ligation

Stripping and ligation involves tying off and removing the greater or lesser saphenous vein and its tributaries. Most of the visible varicosities can then be removed either by multiple incisions or by sclerotherapy.

Endovenous Radiofrequency Ablation (EFRA)

Endovenous radiofrequency ablation (EFRA) of the greater saphenous vein is another minimally invasive alternative to vein stripping and ligation. This method damages the intimal wall of the vessel by delivering high-frequency radiowaves via a specially designed catheter. Heat produced by these radiowaves collapses the vein, causing the vessel to close upon slow withdrawal of the catheter. The VNUS Closure® System (VNUS Medical Technologies, Inc., San Jose, CA) is a radiofrequency device that is approved by the US Food and Drug Administration (FDA) for the endovascular coagulation of blood vessels in individuals with superficial vein reflux.

Endovenous Laser Ablation (EVLT)

Endovenous laser ablation therapy (EVLT) of the saphenous veins is a minimally invasive alternative to vein stripping and ligation. Under ultrasound guidance, a bare-tipped laser is introduced into the greater saphenous vein, activated, and slowly withdrawn, causing the vessel to collapse. The Diomed 810-nm Surgical Laser and Endovenous Laser Therapy (EVLT®) Procedure Kit (Diomed, Inc., Andover, MA) are approved by the FDA for the endovascular coagulation of blood vessels in individuals with superficial vein reflux.

Endovenous Mechanochemical Ablation

Endovenous mechanochemical ablation (e.g., Clarivein [Vascular Insights, Madision, CT]) is a minimally invasive treatment for varicose veins, combining mechanical and chemical modalities. The procedure involves the use of a special percutaneous infusion catheter, which contains a rotating wire, providing endovenous mechanical destruction. Simultaneously, an FDA-approved sclerosing agent (e.g., sodium tetradecyl sulfate) is administered in order to enhance occlusion of the vein. Currently, there are ongoing clinical trials involving endovenous mechanochemical ablation versus EFRA. To date, the evidence of endovenous mechanochemical ablation incudes a randomized controlled trial with 117 individuals with short-term follow-up of six months. Loss to follow-up was greater than 20 percent at one and six months across both study arms (Lane 2017). These short-term results suggest that intraprocedural pain is slightly lower with endovenous mechanochemical ablation than with EFRA. However, endovenous mechanochemical ablation has been assessed in relatively few individuals and for short durations. Longer follow-up is needed to evaluate the efficacy and durability of this procedure compared to established procedures.

The systematic review from National Institute for Health and Clinical Excellence (NICE 2016) includes clinical practice guidance. Guidelines recommend use of endovenous mechanochemical ablation for the treatment of varicose veins, although they noted that a longer-term follow-up data are needed. The authors did not use a formal quality assessment tool, but noted that the estimate of efficacy for the procedures was limited by short follow-up periods (two years at most) and variations in chemical agents and dosage within and across studies.

Reported limitations of the available evidence include sample sizes, reliance on nonrandomized studies, heterogeneity in protocols for the chemical component and industry funding. The evidence is insufficient to determine the effects of the technology on health outcomes.

Stab Phlebectomy

Stab phlebectomy is a technique of removing varicose veins through multiple small incisions. Stab phlebectomy may be performed in conjunction with stripping and ligation.

Transilluminated Powered Phlebectomy

Transilluminated powered phlebectomy (e.g., Smith & Nephew TriVex System, [Smith & Nephew, Inc., Andover, MA]) is a minimally invasive procedure in which an endoscopic illuminator is inserted into the vein to allow visualization of the varicose vein clusters. The veins are then ablated using a vein resector. During destruction of the veins, the debris is removed from the wound using suction.

Sclerotherapy

Sclerotherapy involves the destruction of the endothelium (or lining) of the targeted vessels by injection of a sclerosing solution. The accuracy of the injection, an adequate volume of injectant, and the concentration of the sclerosant determine the success of the treatment. Larger veins (greater than 6 mm diameter or the main saphenous veins), and very tortuous veins may not be good candidates for this therapy. Sclerotherapy can be performed in conjunction with surgical treatment of varicose veins of the lower extremities. The sclerotherapy agents currently available are classed by their actions in causing endothelial damage: osmotic or detergent agents. Osmotic agents achieve their effect by dehydrating endothelial cells through osmosis. Hypertonic saline and glycerin are two types of osmotic agents; however, glycerin is currently not commercially available in the United States. Sodium tetradecyl sulfate (Sotradecol®) and polidocanol (Asclera®) are detergent agents, which are surface active agents that cause endothelial damage by interfering with cell membrane lipids. In review of available published literature, a systematic review of 17 randomized controlled trials of injection sclerotherapy for varicosities of varying size found no evidence to support use of one sclerosant over another in the short-term success of sclerotherapy.

In addition to sclerotherapy's use in conjunction with surgical treatment, EVLT and EFRA, it may be utilized solely for aesthetic or cosmetic purposes, an instance being for the treatment of telangiectasia (spider veins). Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiological function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiological function. For example, polidocanol (Asclera®) has potential to be used solely for cosmetic purposes because it was approved by the US Food and Drug Administration as a sclerosing agent indicated to treat uncomplicated spider veins (varicose veins 1mm or less in diameter) and uncomplicated reticular veins (varicose veins 1mm to 3mm in diameter); polidocanol (Asclera®) has not been studied in varicose veins larger than 3 mm.

Sclerotherapy using a liquid sclerosing agent has traditionally been the gold standard; however, foam sclerosing agents are becoming more popular. Foam sclerosants are produced by forcibly mixing a gas (e.g., air, carbon dioxide) with a liquid sclerosant (i.e., polidocanol, sodium tetradecyl sulfate), allowing for a larger surface area of exposure. The expanded volume of the foam compared with liquid agents has exhibited more surface contact, a more uniform vessel closure, and the need for smaller volumes of sclerosant. The rates of occlusion with the FDA-approved microfoam scleroherapy are similar to those reported for endovenous laser ablation or stripping. Varithena (formerly known as Varisolve®, BTG PLC, London) is a sclerosant microfoam made with proprietary gas mix. Varithena received FDA approval in 2013, under a new drug application (NDA) for the treatment of incompetent great saphenous veins, accessory saphenous veins, and visible varicosities of the great saphenous vein system above and below the knee.

Cyanoacrylate Adhesive

Cyanoacrylate adhesive is a clear, free-flowing liquid that polymerizes in the vessel via an anionic mechanism (i.e., polymerizes into a solid material upon contact with body fluids or tissue). Under local anesthesia, the adhesive is gradually injected along the length of the vein in conjunction with ultrasound and manual compression. The acute coaptation halts blood flow through the vein until the implanted adhesive, typically delivered in measured doses becomes fibrotically encapsulated and establishes chronic occlusion of the treated vein.

The VenaSeal® Closure System (Sapheon, a part of Medtronic), which seals the vein using cyanoacrylate adhesive agent, received FDA approval in 2015 for the permanent closure of clinically significant venous reflux through endovascular embolization with coaptation. However, evidence on cyanoacrylate adhesive for the treatment of varicose veins and venous insufficiency includes a multicenter noninferiority trial with three months of follow-up and case series with longer follow-up. The short-term efficacy of cyanoacrylate adhesive has been shown to be noninferior to EFRA at three months. Longer follow-up in trials with a larger number of individuals is needed to determine durability of this treatment.

Gibson and Ferris (2017) reported results of the prospective WAVES study of cyanoacrylate closure for the treatment of great saphenous veins, small saphenous veins, and/or accessory saphenous veins up to 20 mm in diameter (n=50). Compression stockings post-procedure were not utilized. Participants returned at one week and one month for follow-up. All treated veins (48 great saphenous vein, 14 accessory saphenous veins, and 8 small saphenous veins) had complete closure by duplex ultrasound at seven days and one month. Mean time to return to work and normal activities was 0.2 ± 1.1 and 2.4 ± 4.1 days, respectively. The revised venous clinical severity score was improved to 1.8 ± 1.4 (p < .001) and Aberdeen Varicose Vein Questionnaire score to 8.9 ± 6.6 (p < .001) at one month. Phlebitis in the treatment area or side branches occurred in ten subjects (20 percent) and completely resolved in all but one subject (2 percent) by one month. The authors concluded that cyanoacrylate closure is safe and effective for the treatment of one or more incompetent saphenous or accessory saphenous veins, closure rates were high even in the absence of the use of compression stockings or side branch treatment. Time back to work or normal activities was short and improvements in venous severity scores and QOL were in the authors’ opinion significant, comparing favorably with alternative treatment methods. Randomized controlled trials with a larger number of individuals and longer follow-up periods are needed to validate findings. The evidence is insufficient to determine the effects of the technology on health outcomes.

Cryoablation

Cryoablation uses extreme cold to cause injury to the vessel, causing retraction and subsequent fibrotic occlusion to the vein. For individuals who have varicose veins/venous insufficiency and saphenous vein reflux who receive cryoablation, the evidence includes RCTs and multicenter series. Relevant outcomes are symptoms, change in disease status, morbid events, quality of life, and treatment-related morbidity. Results from a recent RCT of cryoablation have indicated that this therapy is inferior to conventional stripping. Studies showing a benefit on health outcomes are needed. The evidence is insufficient to determine the effects of the technology on health outcomes.

Echosclerotherapy

Echosclerotherapy utilizes duplex ultrasound to guide the injection of the sclerosing solution and to enhance the precision of saphenous vein sclerotherapy. The use of duplex-guided ultrasound for sclerotherapy of varicose veins of the lower extremities has not been shown to definitively increase the effectiveness or safety of this procedure. There is very little published medical literature on the use of echosclerotherapy, and no large long-term outcomes have been reported.

PERFORATOR VEINS AND TREATMENT OF INCOMPETENCE

Perforator veins are an irregular group of veins that grow as tributaries of the greater saphenous veins and connect the superficial venous system to the deep venous system. They permit the unidirectional flow of blood from the superficial to the deep venous system through a set of one-way valves. These valves can become incompetent and have been linked to chronic venous insufficiency (CVI), which is characterized by induration and inflammation of the skin and subcutaneous tissues, as well as microvascular stasis that ultimately leads to tissue destruction and chronic ulceration.

TREATMENT OF PERFORATOR VEIN INCOMPETENCE
Surgical treatment of incompetent perforator veins as a treatment for CVI can be performed by an open approach, endoscopic approach, or by endovenous radiofrequency or laser ablation. The original treatment approach was the Linton procedure, an open approach, which involved a long medial calf incision to expose posterior, medial, and paramedial perforators. This procedure was associated with the healing of ulcers but, over time, has been largely abandoned due to incidences of wound complications. As a result, the Linton procedure's approach was modified to a series of perpendicular skin flaps instead of a longitudinal skin flap to provide access to incompetent perforator veins in the lower part of the leg. This modified Linton procedure may be used for the closure of incompetent perforator veins that cannot be accessed by less invasive procedures. Subfascial endoscopic perforator surgery (SEPS) is a minimally invasive procedure whereby duplex ultrasound guidance is used, and small incisions are made in the skin. Using endoscopic techniques, the perforator veins are clipped or divided by endoscopic scissors. EFRA and EVLT are utilized in a similar fashion as with incompetent saphenous veins, as described above.
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Wallace T, El-Sheikha J, Nandhra S, et al. Long-term outcomes of endovenous laser ablation and conventional surgery for great saphenous varicose veins. Br J Surg. 2018;105(13):1759-1767.

Zierau U. Sealing Veins with the VenaSeal Sapheon Closure System: Results for 795 Treated Truncal Veins after 1000 Days. Vasomed. 2015;27:124-127.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785

THE FOLLOWING CODE IS USED TO REPRESENT LIGATION USING THE TRIVEX SYSTEM:
37799

EXPERIMENTAL/INVESTIGATIONAL
0524T, 36473, 36474, 36482, 36483

COSMETIC
36468



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

MEDICALLY NECESSARY

I78.0 Hereditary hemorrhagic telangiectasia

I78.8 Other diseases of capillaries

I80.00 Phlebitis and thrombophlebitis of superficial vessels of unspecified lower extremity

I80.01 Phlebitis and thrombophlebitis of superficial vessels of right lower extremity

I80.02 Phlebitis and thrombophlebitis of superficial vessels of left lower extremity

I80.03 Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateral

I80.3 Phlebitis and thrombophlebitis of lower extremities, unspecified

I83.001 Varicose veins of unspecified lower extremity with ulcer of thigh

I83.002 Varicose veins of unspecified lower extremity with ulcer of calf

I83.003 Varicose veins of unspecified lower extremity with ulcer of ankle

I83.004 Varicose veins of unspecified lower extremity with ulcer of heel and midfoot

I83.005 Varicose veins of unspecified lower extremity with ulcer other part of foot

I83.008 Varicose veins of unspecified lower extremity with ulcer other part of lower leg

I83.009 Varicose veins of unspecified lower extremity with ulcer of unspecified site

I83.011 Varicose veins of right lower extremity with ulcer of thigh

I83.012 Varicose veins of right lower extremity with ulcer of calf

I83.013 Varicose veins of right lower extremity with ulcer of ankle

I83.014 Varicose veins of right lower extremity with ulcer of heel and midfoot

I83.015 Varicose veins of right lower extremity with ulcer other part of foot

I83.018 Varicose veins of right lower extremity with ulcer other part of lower leg

I83.019 Varicose veins of right lower extremity with ulcer of unspecified site

I83.021 Varicose veins of left lower extremity with ulcer of thigh

I83.022 Varicose veins of left lower extremity with ulcer of calf

I83.023 Varicose veins of left lower extremity with ulcer of ankle

I83.024 Varicose veins of left lower extremity with ulcer of heel and midfoot

I83.025 Varicose veins of left lower extremity with ulcer other part of foot

I83.028 Varicose veins of left lower extremity with ulcer other part of lower leg

I83.029 Varicose veins of left lower extremity with ulcer of unspecified site

I83.10 Varicose veins of unspecified lower extremity with inflammation

I83.11 Varicose veins of right lower extremity with inflammation

I83.12 Varicose veins of left lower extremity with inflammation

I83.201 Varicose veins of unspecified lower extremity with both ulcer of thigh and inflammation

I83.202 Varicose veins of unspecified lower extremity with both ulcer of calf and inflammation

I83.203 Varicose veins of unspecified lower extremity with both ulcer of ankle and inflammation

I83.204 Varicose veins of unspecified lower extremity with both ulcer of heel and midfoot and inflammation

I83.205 Varicose veins of unspecified lower extremity with both ulcer other part of foot and inflammation

I83.208 Varicose veins of unspecified lower extremity with both ulcer of other part of lower extremity and inflammation

I83.209 Varicose veins of unspecified lower extremity with both ulcer of unspecified site and inflammation

I83.211 Varicose veins of right lower extremity with both ulcer of thigh and inflammation

I83.212 Varicose veins of right lower extremity with both ulcer of calf and inflammation

I83.213 Varicose veins of right lower extremity with both ulcer of ankle and inflammation

I83.214 Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation

I83.215 Varicose veins of right lower extremity with both ulcer other part of foot and inflammation

I83.218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation

I83.219 Varicose veins of right lower extremity with both ulcer of unspecified site and inflammation

I83.221 Varicose veins of left lower extremity with both ulcer of thigh and inflammation

I83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammation

I83.223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation

I83.224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation

I83.225 Varicose veins of left lower extremity with both ulcer other part of foot and inflammation

I83.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation

I83.229 Varicose veins of left lower extremity with both ulcer of unspecified site and inflammation

I83.811 Varicose veins of right lower extremity with pain

I83.812 Varicose veins of left lower extremity with pain

I83.813 Varicose veins of bilateral lower extremities with pain

I83.819 Varicose veins of unspecified lower extremity with pain

I83.891 Varicose veins of right lower extremity with other complications

I83.892 Varicose veins of left lower extremity with other complications

I83.893 Varicose veins of bilateral lower extremities with other complications

I83.899 Varicose veins of unspecified lower extremity with other complications

I87.2 Venous insufficiency (chronic) (peripheral)

THE SERVICES INCLUDED IN THIS POLICY ARE CONSIDERED COSMETIC WHEN REPORTED WITH ANY OF THE FOLLOWING CODES:

I83.90 Asymptomatic varicose veins of unspecified lower extremity

I83.91 Asymptomatic varicose veins of right lower extremity

I83.92 Asymptomatic varicose veins of left lower extremity

I83.93 Asymptomatic varicose veins of bilateral lower extremities



HCPCS Level II Code Number(s)

NOT MEDICALLY NECESSARY

S2202 Echosclerotherapy



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 11.02.01r:
04/01/2019This version of the policy will become effective 04/01/2019. The intent of this policy remains unchanged, but the policy was updated to further clarify criteria and introduce provider accreditation requirements to the policy.

Revisions from 11.02.01q:
01/01/2019Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.

This policy has been identified for the CPT code update, effective 01/01/2019.

The following CPT code has been added to this policy:

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

Revisions from 11.02.01p:
03/27/2018This version of the policy will become effective 03/27/2018.

The following criteria have been added to this policy:
  • Qualifications have been added to the symptomatic medically necessary indications

The following criteria have been revised in this policy:
  • Removal of sclerotherapy treatment for symptomatic greater or lesser saphenous varicose veins/chronic venous insufficiency.

The coverage position has been revised from medically necessary to experimental/investigational for endovenous mechanochemical ablation of any vein.

Revisions from 11.02.01o:
01/01/2018This policy has been identified for the CPT code update, effective 01/01/2018.

The following CPT codes have been added to this policy:

36465 (Medically Necessary), 36466 (Medically Necessary), 36482 (Experimental/Investigational), 36483 (Experimental/Investigational)

The following CPT code narratives have been revised in this policy:

36468, 36470, 36471


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 04/01/2019
Version Issued Date: 04/01/2019
Version Reissued Date: N/A

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