Medicare Advantage

Medical Policy

Notification

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

Notification Issue Date:

This version of the policy published on 01/13/2025 with a retro-effective date of 03/11/2021.

Revisions were updated in accordance with CMS to allow coverage of sclerotherapy, including ultrasound-guided foam sclerotherapy, and liquid sclerotherapy and cyanoacrylate adhesive in the treatment of saphenous veins.

Additional medically necessary coverage statements were added for bulbous varicosities and venous malformations, and telangiectasia with the presence of spontaneous and/or traumatic venous hemorrhage. Experimental/investigational coverage statements were added for catheter-assisted vein sclerotherapy with ballon isolation.

The coverage position for the following code was revised from cosmetic to medically necessary: 36468. The coverage position for the following codes was revised from experimental/Investigational to medically necessary: 36482, 36483. The coverage position for the following code was revised from Not Medically Necessary to Medically Necessary: S2202 Echosclerotherapy. The following NOC code was added to the policy as to represent stab phlebectomy fewer than 10 incisions: 37799 (Medically Necessary)

A coding/billing requirement to provide direction on correct coding for sclerotherapy treatment of tributaries and physician compounded foam was added.

Title:

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

Policy #:

MA11.001l

Policy

This policy uses coverage criteria primarily based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents. In the absence of fully established coverage criteria from these Medicare coverage documents for a specific medical service or item, the criterion/indication/service indicated by an asterisk below (*) is based on internal coverage criteria developed by the Company in consideration of peer-reviewed medical literature, clinical practice guidelines, regulatory status, and/or expert opinion.

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.

MEDICALLY NECESSARY

GREAT OR SMALL SAPHENOUS VEINS, INCLUDING ACCESSORY SAPHENOUS VEINS AND/OR DUPLICATE SAPHENOUS VEINS, INCLUDING ACCESSORY SAPHENOUS VEINS
Surgery (i.e., Stripping and Ligation), Endovenous Thermal (Radiofrequency or Laser) Ablation Therapy, Ultrasound-Guided Foam Sclerotherapy (UGFS), Physician-Compounded Foam (PCF) and Noncompounded Foam (NCF), Liquid Sclerotherapy, Endovenous Mechanochemical Ablation or Cyanoacrylate Adhesives

The treatment of symptomatic great or small saphenous varicose veins/chronic venous insufficiency, including the accessory saphenous veins and/or duplicate saphenous veins, by surgery (i.e., stripping and ligation), endovenous thermal (radiofrequency or laser) ablation therapy, UGFS, PCF and NCF, liquid sclerotherapy, endovenous mechanochemical ablation or cyanoacrylate adhesives are considered medically necessary and, therefore, covered when ALL of the following criteria are met:

An evaluation using the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) clinical classification and the revised Venous Clinical Severity Score (VCSS) were performed, AND
A duplex scan of the deep and superficial venous systems supports the examination findings, AND
A duplex scan confirms the presence of reversed venous flow (reflux) with provocative maneuvers in the saphenous or perforator vein is 500 milliseconds or greater and absence of deep venous obstruction, AND
The documentation supports signs and/or symptoms that interfere with activities of daily living and/or quality of life, AND
The CEAP clinical classification is C1 to C6 with the following criteria:

Treatment of C1 disease (telangiectasia and their feeding reticular veins) is considered medically necessary for individuals with spontaneous and/or traumatic venous hemorrhage.
For individuals with C2 or C3 disease and VCSS less than 6, the plan of care shall include documentation of a period of conservative therapy (2 to 4 weeks) including graduated compression 20 to 30 mm Hg or greater, ambulation, elevation, and avoiding prolonged sitting and standing.
For individuals who meet any one of the following criteria, the mandatory conservative therapy prior to the invasive procedure may be waived.
- VCSS greater than or equal to 6
- C4-C6 disease (skin changes assigned to venous disease, healed venous leg ulceration, and active venous leg ulceration)
- Hemorrhage
- Recurrent superficial thrombophlebitis

SAPHENOFEMORAL JUNCTION OR SAPHENOPOPLITEAL JUNCTION

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* (Zhao et al., 2015).

SYMPTOMATIC VARICOSE TRIBUTARIES

The following treatments are considered medically necessary for the treatment of symptomatic varicose tributaries:

Stab avulsion* (Gloviczki et al., 2011; Gloviczki et al., 2024)
Hook phlebectomy* (Gloviczki et al., 2011; Gloviczki et al., 2024)
Sclerotherapy, including UGFS, PCF, NCF, and liquid sclerotherapy
Transilluminated powered phlebectomy (the Trivex system)* (Luebke and Brunkwall, 2008a and b; Luebke et al., 2008; Chetter et al., 2006)

When saphenous vein ablation is performed, phlebectomy (i.e., hook, stab avulsion, or TIPP) is considered medically necessary, and therefore, covered when performed as a staged or concomitant treatment.

INCOMPETENT PERFORATOR VEINS (IPV)

Subfascial Endoscopic Perforator Vein Surgery (SEPS)* (Ho et al., 2022), Endovenous Thermal Ablation (Radiofrequency or Laser), or Foam Sclerotherapy

Subfascial endoscopic perforator vein surgery (SEPS), endovenous thermal ablation (radiofrequency or laser), or foam sclerotherapy of perforator vein incompetence is considered medically necessary and, therefore, covered as a treatment of leg ulcers associated with chronic venous insufficiency when ANY of the following criteria are met:

An active venous ulcer is in close proximity to the IPV
The proximal significant reflux has been treated and an IPV persists under or adjacent to a healed venous ulcer
The proximal and regional venous reflux has been treated and there is persisting focal pain and tenderness or stasis dermatitis overlying an IPV,
Duplex ultrasound studies of the venous system demonstrate perforator vein reflux (i.e., reflux >0.5-second duration and diameter >3.5 mm) that correlates with the individual's symptoms

TELANGIECTASIA/SPIDER VEIN/RETICULAR VEIN
Treatment of telangiectasia (spider veins) and their feeding reticular veins by sclerotherapy with injectable liquid are considered medically necessary and, therefore, covered on an individual basis only if there is associated spontaneous and/or traumatic venous hemorrhage.

BULBOUS VARICOSITIES

Ambulatory phlebectomy/stab phlebectomy of symptomatic bulbous varicosities are considered medically necessary and, therefore, covered when the bulbous varicosity is greater than 3 mm in diameter and above or below the knee.

VENOUS MALFORMATIONS

Ultrasound-guided foam sclerotherapy (UGFS) is considered medically necessary and, therefore, covered for ablation of venous malformations.

EXPERIMENTAL/INVESTIGATIONAL

ENDOVENOUS THERMAL (RADIOFREQUENCY OR LASER) ABLATION OF TRIBUTARY VEINS
Endovenous thermal (radiofrequency or laser) ablation of tributary veins is 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* (Hamel-Desnos et al., 2023; Viljamaa et al., 2023).

CATHETER-ASSISTED VEIN SCLEROTHERAPY WITH BALLOON ISOLATION

Catheter-assisted vein sclerotherapy with ballon isolation 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* (Brodersen and Geismar, 2007).

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* (Klem et al., 2009; Disselhoff et al., 2008 and 2011).

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) without the presence of spontaneous and/or traumatic venous hemorrhage by sclerotherapy or any other treatment, which does not meet the policy criteria above are not covered by the Company because they are 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.

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. To access the requirements, visit: https://www.ibx.com/providers/interactive_tools/credentialing/professional.html.

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 3-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

This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, the following procedures are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met:

Stripping and ligation of varicose veins
Ambulatory or stab phlebectomy
Sclerotherapy, including ultrasound-guided foam sclerotherapy (UGFS), and liquid sclerotherapy
Endovenous thermal (radiofrequency or laser) ablation
Endomechanical ablation
Transilluminated powered phlebectomy
Cyanoacrylate adhesives
Surgical treatment of perforator vein incompetence

However, services that are experimental/investigational are excluded for the Company's Medicare Advantage products. Therefore, they are not eligible for reimbursement consideration.

Services that are cosmetic are excluded for the Company’s Medicare Advantage products because they are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

CONSERVATIVE MEDICAL MANAGEMENT THERAPY

Conservative medical management therapy refers to the nonsurgical management of varicose veins, which includes the use of graduated compression stockings or wraps, periodic leg elevation, weight reduction as appropriate, mild exercise, avoidance of long periods of standing, and analgesia for symptom relief. Leg elevation helps venous return and decreases venous hypertension.

Compression stockings are defined as graduated elasticized compression stockings. Use of nongraduated 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. Compression therapy is an important adjunct for individuals with advanced signs of venous insufficiency, especially those with edema, skin changes, and venous stasis ulcers (C3-C6).

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 atrophie blanche
C5: Healed venous ulcer

C6: Active venous ulcer

THE VENOUS CLINICAL SEVERITY SCORE (VCSS)

The venous clinical severity score (VCSS) system includes 10 clinical descriptors (pain, varicose veins, venous edema, skin pigmentation, inflammation, induration, number of active ulcers, duration of active ulceration, size of ulcer, and compressive therapy use), scored from 0 to 3 (none, mild, moderate, severe, for a total possible score equal to 30) that may be used to assess changes in response to therapy.

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 ≤1 mm in diameter) and uncomplicated reticular veins (varicose veins 1–3 mm in diameter).

VenaSeal® Closure System was approved by the FDA in February 2015 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 great and small saphenous veins, accessory veins, and rare variant duplicate great saphenous veins (GSVs; veins that travel in parallel with the great and small 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.

Superficial veins, which are located between the deep fascia and the skin, include the telangiectasia veins, the reticular veins, and the main axial (truncal) superficial vein. The term "varicose veins" does not include telangiectatic dermal vessels (e.g., "spider veins" or "broken blood vessels"). Spider veins (also known as telangiectases) are small, dilated, flat, thin-walled, blue or red veins smaller than 1 mm in diameter and have a web-like appearance on the surface of the skin. The primary difference between spider veins and varicose veins is that spider veins primarily 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. In rare incidences, telangiectases may have spontaneous and/or traumatic venous hemorrhages. Sclerotherapy has been proposed as a treatment option for hemorrhagic telangiectases.

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 surgery (i.e., stripping and ligation), endovenous thermal (radiofrequency or laser) ablation therapy, stab avulsion or hook phlebectomy, sclerotherapy, both with injectable liquid and microfoam, including with ultrasound-guided transilluminated powered phlebectomy (TIPP), and subfascial endoscopic perforator surgery (SEPS), and cyanoacrylate adhesive.

CLINICAL-ETIOLOGY-ANATOMY-PATHOPHYSIOLOGY (CEAP) CLASSIFICATION
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 on 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 great or small saphenous vein and its tributaries. Most of the visible varicosities can then be removed either by multiple incisions, with the use of cyanoacrylate adhesive, or by sclerotherapy.

Endovenous Thermal Ablation Therapy

Radiofrequency
Endovenous radiofrequency ablation (RFA) of the GSV 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.

Laser
Endovenous laser ablation 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 GSV, 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 (MOCA; e.g., Clarivein™ [Vascular Insights, Madison, 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 to enhance occlusion of the vein.

Four randomized controlled trials (RCTs) with over 100 individuals each (range, 132–213) have been identified that compared MOCA to thermal ablation. The earliest two publications (Bootun et al. [2016], Lane et al. [2017]) reported on early results from an RCT of 170 individuals that compared ClariVein with RFA. Maximum visual analog score (VAS) pain scores (of 100) during the procedure were significantly lower in the MOCA group (median, 15 mm) than in the RFA group (median, 34 mm; P=0.003). Average VAS pain scores during the procedure were also modestly lower in the MOCA group (median, 10 mm) than in the RFA group (median, 19.5 mm; P=0.003). Occlusion rates, clinical severity scores, disease-specific quality of life (QOL), and generic QOL scores were similar between the groups at 1 and 6 months. Only 71% of individuals were available for follow-up at 6 months, limiting the evaluation of closure rates during short term follow-up period.

Vahaaho et al. (2019) reported an RCT that compared MOCA with endovenous thermal ablation (endovenous laser ablation or RFA). Liquid sclerosant at a concentration of 1.5% was used. Of 132 individuals enrolled, seven were later excluded and 117 (88.6%) attended the 1-year follow-up evaluation. Occlusion of the GSV was observed in 45 of 55 (82%) of the MOCA group compared to 100% of the endovenous laser ablation and RFA groups (P=0.002). Another randomized trial by Lam et al. (2016) reported interim results of a dose-finding study, finding greater closure with the use of polidocanol 2% or 3% (liquid) than with polidocanol 1%. Therefore, it is uncertain whether the concentration of sclerosant in the study by Vahaaho et al. (2019) was optimal.

Three percent polidocanol was tested in the MARADONA (Mechanochemical endovenous Ablation to RADiOfrequeNcy Ablation) noninferiority trial reported by Holewijn et al. (2019). Although the study was powered for 400 participants, only 213 individuals were randomly assigned before reimbursement for the procedure was suspended. Pain scores in the 14 days after the procedure were slightly lower, but hyperpigmentation was higher. Anatomic failures were significantly greater in the MOCA group at 1 year and approached significance at 2 years; with the note that the study was underpowered for anatomic failures because of the early stoppage of the study. At 1 and 2 years, clinical and QOL outcomes were similar across the two groups.

A fourth RCT reported by Mohamed et al. (2020) is the ongoing LAMA (Randomized Clinical Trial Comparing Endovenous Laser Ablation and Mechanochemical Ablation [ClariVein] in the Management of Superficial Venous Insufficiency) trial. Individuals (n=150) were randomly assigned to MOCA with 1.5% sodium tetradecyl sulfate or to endovenous laser ablation. Anatomic success (occlusion) rates were lower in the MOCA group (77%) compared to the endovenous laser ablation group (91%) with no significant difference between the two treatments in intraprocedural pain scores. In contrast to the difference in anatomical occlusion rates, clinical severity and QOL scores were not significantly different between the groups at 1-year follow-up. Follow-up is continuing to evaluate the durability of the treatments.

Summary of Evidence for Endovenous Mechanochemical Ablation

MOCA is a combination of liquid sclerotherapy and mechanical abrasion of the lumen. The evidence on MOCA includes four RCTs that compared MOCA to thermal ablation with 6 month to 2-year results, and a prospective cohort with follow-up out to 5 years. Results to date have been mixed regarding a reduction in intraprocedural pain, which is a proposed benefit of MOCA compared to thermal ablation procedures. Occlusion rates at 6 months to 2 years in the RCTs indicate lower anatomic success rates compared to thermal ablation, but a difference in clinical outcomes at these early time points has not been observed. Experience with other endoluminal ablation procedures suggests that lower anatomic success in the short term is associated with recanalization and clinical recurrence between 2 to 5 years. The possibility of later clinical recurrence is supported by a prospective cohort study with 5-year follow-up following treatment with MOCA. However, there have been improvements in technique since the cohort study was begun, and clinical progression is frequently observed with venous disease. Because of these limitations, longer follow-up of the more recently conducted RCTs is needed to establish the efficacy and durability of this procedure compared with the criterion standard of thermal ablation.

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 (the TriVex System)

Transilluminated powered phlebectomy (e.g., the 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. 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 RCTs 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, endovenous thermal ablation (radiofrequency and laser) therapy it may be utilized solely for aesthetic or cosmetic purposes, an instance being for the treatment of telangiectasia (spider veins) without the presence of spontaneous and/or traumatic venous hemorrhage. 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, a product such as polidocanol (Asclera®) has potential to be used solely for cosmetic purposes because it was approved by the FDA as a sclerosing agent indicated to treat uncomplicated spider veins (varicose veins ≤1 mm in diameter) and uncomplicated reticular veins (varicose veins 1–3 mm in diameter); polidocanol (Asclera®) has not been studied in varicose veins larger than 3 mm.

Sclerotherapy using a liquid sclerosing agent previously has been the gold standard; however, foam sclerosing agents have emerged as a popular therapy option in the treatment of varicose veins, tributaries, and telangiectases. 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 sclerotherapy 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 GSVs, accessory saphenous veins, and visible varicosities of the GSV system above and below the knee.

A Cochrane review of 28 studies by de Ávila Oliveira et al. (2021) concluded that there is low-certainty evidence that sclerotherapy is effective and safe compared to placebo for treating cosmetic appearance, persistent symptoms, and QOL concerns related to varicose veins. Evidence was limited or lacking for comparisons of foam with liquid sclerotherapy or other substances, and between concentrations of foam. Sclerotherapy and phlebectomy are considered appropriate in the absence of reflux of the saphenous system (e.g., post- or adjunctive treatment to other procedures such as surgery).

Ultrasound-Guided Sclerotherapy

Ultrasound sclerotherapy utilizes duplex ultrasound to guide the injection of the sclerosing solution and to enhance the precision of saphenous vein sclerotherapy. This procedure may be referred to as echosclerotherapy or ultrasound-guided sclerotherapy. Foam sclerotherapy is a procedure that is performed under ultrasound guidance. There are different types of foam: physician-compounded foam (PCF) and noncompounded foam (NCF). The target, non-target, perforating, and adjacent deep veins are evaluated by ultrasound. UGFS is used for treatment of primary and recurrent varicose veins, including the distal GSV and SSV, perforating veins, and venous malformations. The goal of ultrasound-guided foam sclerotherapy (UGFS) when treating varicose veins is to damage the endothelial surface of the vein to cause scarring and blockage of the treated vein. Under local anesthesia, the sclerosant foam is injected into the affected veins using ultrasound. The foam sclerosant causes an inflammatory reaction in the vein wall, causing vein blockage. Compression bandages are applied following the procedure.

Nesbitt et al. (2014), in a systematic review, compared endovenous ablation (radiofrequency and laser) and foam sclerotherapy to ligation and stripping for GSV varices. The review included 13 randomized studies consisting of a combined 3081 participants. Because of variations in reporting of results, the overall quality of the evidence was deemed to be moderate. The authors concluded that currently available clinical trial evidence suggests that UGFS and endovenous thermal ablation (radiofrequency and laser) are at least as effective as surgery in the treatment of GSVs.

Catheter-Directed Chemical Ablation with Balloon Isolation (KAVS)

Catheter-directed chemical ablation with balloon isolation (KAVS) is a type of catheter-assisted vein sclerotherapy, which involves a double-lumen intravascular catheter with a balloon attached intended to temporarily block the blood flow to the sclerotherapy-treated vein. The evidence base has not developed since initially described in the literature. The evidence base to evaluate the safety and efficacy of KAVS sclerotherapy is limited, and remains insufficient to draw firm conclusions on its use.

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. The technique of cyanoacrylate closure (CAC), which is one of the most common liquid embolic agents, uses a proprietary adhesive for the treatment of refluxing saphenous veins.

Gibson and Ferris (2017) reported results of the prospective WAVES study of CAC for the treatment of GSVs, small saphenous veins, and/or accessory saphenous veins up to 20 mm in diameter (n=50). Compression stockings postprocedure were not utilized. Participants returned at 1 week and 1 month for follow-up. All treated veins (48 GSV, 14 accessory saphenous veins, and eight small saphenous veins) had complete closure by duplex ultrasound at 7 days and 1 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<0.001) and Aberdeen Varicose Vein Questionnaire score to 8.9 ± 6.6 (P<0.001) at 1 month. Phlebitis in the treatment area or side branches occurred in 10 subjects (20%) and completely resolved in all but one subject (2%) by 1 month. The authors concluded that CAC 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.

The VenaSeal pivotal study (VeClose), a multicenter noninferiority trial with 222 enrollees, compared VenaSeal with RFA for the treatment of venous reflux. The pivotal registration study for the VeClose study and follow-up through 36 months report that the primary endpoint (the proportion of individuals with complete closure of the target GSV at 3 months measured by ultrasound) was noninferior to RFA, with a 99% closure rate for VenaSeal compared with 96% for RFA. The secondary endpoint (intraoperative pain) was similar for both groups (2.2 on a 10-point scale for VenaSeal vs. 2.4 for RFA; P=0.11). Ecchymosis at day 3 was significantly lower in the cyanoacrylate group; 67.6% of individuals treated with cyanoacrylate had no ecchymosis compared with 48.2% of individuals following RFA (P<0.01). Scores on the AVVQ and Venous Clinical Severity Score improved to a similar extent in both groups. The mean time to return to work in a prospective cohort of 50 participants reported by Gibson and Ferris (2017) was 0.2 days.

For the CAC and RFA groups, the complete occlusion rates were 97.2% and 97.0%. Freedom from recanalization was also similar between the two groups (P=0.08). Twenty-four-month results were reported by Gibson et al. (2018), which included 171 participants (87 from CAC and 84 from RFA). Thirty-six-month results were reported by Morrison et al. (2019), with follow-up on 146 (66%) individuals (72 from CAC and 74 from RFA). Loss to follow-up was similar in the two groups. The complete closure rates for CAC and RFA were 94.4% and 91.9% (P=0.005 for noninferiority), respectively. Recanalization-free survival through 36 months was not statistically different for the two groups. No significant device- or procedure-related adverse events were reported for either group.

VariClose CAC was compared with RFA and endovenous laser ablation by Eroglu and Yasim (2018) in an RCT with 525 individuals. Periprocedural outcomes showed a shorter intervention time, less pain, and shorter return to work with CAC compared to endovenous thermal ablation. There was no significant difference in occlusion rates among the three treatments at 6, 12, and 24-month follow-up.

Alhewy et al. (2024) conducted an RCT at two centers in Egypt comparing VenaSeal CAC with RFA in 248 participants with venous reflux, with follow-up extending to 2 years postprocedure. The primary outcome was complete closure of the target GSV at the 3-month visit, although results for this outcome were not reported by the authors. The authors reported that at the 1-month follow-up, all veins treated with CAC remained occluded, while 154 of 158 (97%) veins treated with RFA remained occluded. At 24 months, 122 of 128 (95%) veins treated with CAC and 146 of 158 (93%) veins treated with RFA remained occluded. At month 24, there were six recanalizations in the CAC group and 12 in the RFA group, with recanalization-free survival in the CAC group found to be noninferior to that of the RFA group (95.3% vs. 92.4%, respectively; P<0.0001 for 10% noninferiority). The CAC group experienced fewer complications, with only two cases of paresthesia and 18 cases of bruises reported, whereas the RFA group encountered 18 cases of bruises, two cases of skin burns, and two cases of access site hematoma. Periprocedural outcomes showed a potentially shorter intervention time with CAC versus RFA.

Summary of Evidence for Cyanoacrylate Adhesive

Evidence assessing CAC for the treatment of varicose veins and venous insufficiency includes a multicenter noninferiority trial with follow-up through 36 months, two RCTs with follow-up through 24 months, and a prospective cohort with 30 months of follow-up. The short-term efficacy of VenaSeal CAC has been shown to be noninferior to RFA at up to 36 months of follow-up. At 24 and 36 months, the study had greater than 20% loss to follow-up, but loss to follow-up was similar in the two groups at the long-term follow-up and is not expected to influence comparative results. Another RCT (N=248) comparing VenaSeal CAC with RFA found similar proportions of vein closures at 24 months with both treatments (100% and 95%, respectively; P value not reported), with potentially shorter procedure duration with CAC versus RFA (25–54 minutes and 40–70 minutes, respectively; P value not reported). An RCT (N=525) with an active CAC ingredient (N-butyl cyanoacrylate) that is currently available outside of the United States found no significant differences in vein closure between CAC and thermal ablation controls at 24 months of follow-up. The CAC procedure and return to work were shorter and pain scores were lower compared to thermal ablation; the subjective pain scores may have been influenced by differing expectations in this study. A prospective cohort reported high closure rates at 30 months. Overall, results indicate that outcomes from CAC are at least as good as thermal ablation techniques, the current standard of care.

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, QOL, 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.

PERFORATOR VEINS AND TREATMENT OF INCOMPETENCE

Perforator veins are an irregular group of veins that grow as tributaries of the GSVs 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.

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. 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.

Endovenous thermal, both radiofrequency and laser, ablation therapies are utilized in a similar fashion as with incompetent saphenous veins, as described above.

Giannopoulos et al. (2022) performed a systematic review of percutaneous treatments for pathologic perforating veins. Thirty-five studies met the inclusion criteria (five double-arm studies and 28 single-arm studies). Endovenous laser ablation (with or without microphlebectomy and/or sclerotherapy) was successful within the first 2 weeks after the procedure in 95% of individuals. Success rates for RFA (with or without microphlebectomy) were 91% (95% CI, 75–99). Ultrasound-guided sclerotherapy had a success rate of 70% after multiple sessions (95% CI, 53–84). After 12 months of follow-up, occlusion rates were 89%, 77%, and 83% in the three groups, respectively. Limitations of the review include heterogeneity of the interventions in the included studies, including adjuvant therapy that could be provided at the investigator's discretion.

Ho et al. (2022) published a systematic review to compare interventions for incompetent perforator veins, including open ligation, SEPS, endovascular laser ablation, ultrasound-guided sclerotherapy, and RFA. Eighty-one studies (N=7010) were identified, and the overall quality of evidence was low to intermediate. Results demonstrated that in the short term (≤1 year), efficacy rates for wound healing were 99.9% for ultrasound-guided sclerotherapy, 72.2% for open ligation, and 96.0% for SEPS. For short-term freedom from wound recurrence, the pooled estimate for SEPS was 91.0%; wound recurrence rates were not reported for other interventions.

References

Alaiti S. Sclerotherapy treatment & management. [Medscape Web site]. 07/10/2023. Available at: http://emedicine.medscape.com/article/1271091-treatment#showall. Accessed May 14, 2026.

Alhewy MA, Abdo EM, Ghazala EAE, et al. Outcomes of Cyanoacrylate Closure Versus Radiofrequency Ablation for the Treatment of Incompetent Great Saphenous Veins. Ann Vasc Surg. 2024;98:309-316.

Attaran RR, Edwards ML, Arena FJ, et al. 2025 SCAI Clinical Practice Guidelines for the Management of Chronic Venous Disease: This statement was endorsed by the Society for Vascular Medicine (SVM). J Soc Cardiovasc Angiogr Interv. 2025;4(8):103729.

Barwell JR, Davies CE, Deacon J, et al. Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomized controlled trial. Lancet. 2004;363(9424):1854-1859.

Bianchi C, Ballard JL, Abou-Zamzam A, et al. Subfascial endoscopic perforator vein surgery combined with saphenous vein ablation: results and critical analysis. J Vasc Surg. 2003;38(1):67-71.

Bergan JJ, Schmid-Schonbein GW, Coleridge Smith PD, et al. Chronic venous disease. N Engl J Med. 2006;355(5):488-498.

Blaise S, Bosson JL, Diamand JM. Ultrasound-guided sclerotherapy of the great saphenous vein with 1% vs 3% polidocanol foam: a multicentre double-blind randomized trial with 3-year follow-up. Eur J Vasc Endovasc Surg. 2010;39(6):779-786.

Blomgren L, Johansson G, Dahlberg-Akerman A, et al. Changes in superficial and perforating vein reflux after varicose vein surgery. J Vasc Surg. 2005;42(2):315-320.

Boersma D, Kornmann VNN, Van Eekeren RRJP, et al. Treatment modalities for small saphenous vein insufficiency: systematic review and meta-analysis. J Endosc Ther. 2016;23(1):199-211.

Bootun R, Lane TR, Dharmarajah B, et al. Intra-procedural pain score in a randomised controlled trial comparing mechanochemical ablation to radiofrequency ablation: The Multicentre Venefit™ versus ClariVein® for varicose veins trial. Phlebology. 2016;31(1):61-65.

Boyle E, Drgastin, R, Labropoulos N, et al. The anterior saphenous vein. Part 4. Clinical and technical considerations in treatment. Endorsed by the American Vein and Lymphatic Society, the American Venous Forum, and the International Union of Phlebology. May 2024. J Vasc Surg Venous Lymphat Disord. 2024;12(3):101857.

Brittenden J, Cooper D, Dimitrova M, et al. Five-year outcomes of a randomized trial of treatments for varicose veins. N Engl J Med. 2019;381(10):912-922.

Brodersen JP, Geismar U. Catheter-assisted vein sclerotherapy: a new approach for sclerotherapy of the greater saphenous vein with a double-lumen balloon catheter. Dermatol Surg. 2007 Apr;33(4):469-475.

Chetter IC, Mylankal KJ, Hughes H, Fitridge R. Randomized clinical trial comparing multiple stab incision phlebectomy and transilluminated powered phlebectomy for varicose veins. Br J Surg. 2006;93(2):169-174.

Christenson JT, Gueddi S, Gemayel G, et al. Prospective randomized trial comparing endovenous laser ablation and surgery for treatment of primary great saphenous varicose veins with a 2-year follow-up. J Vasc Surg. 2010;52(5):1234-1241.

Coleridge Smith P. Sclerotherapy and foam sclerotherapy for varicose veins. Phlebology. 2009;24(6):260-269.

Disselhoff BC, der Kinderen DJ, Kelder JC, et al. Randomized clinical trial comparing endovenous laser with cryostripping for great saphenous varicose veins. Br J Surg. 2008;95(10):1232-1238.

Disselhoff BC, der Kinderen DJ, Kelder JC, et al. Five-year results of a randomized clinical trial comparing endovenous laser ablation with cryostripping for great saphenous varicose veins. Br J Surg. 2011;98(8):1107-1111.

de Ávila Oliveira R, Riera R, Vasconcelos V, et al. Injection therapy for varicose veins. Cochrane Database Syst Rev. 2021 Dec 10;12(12):CD001732.

De Maeseneer M, Kakkos, S, Aherne T, et al. European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg. 2022;63:184e267.

Elias S, Khilnani N. Treating the small saphenous vein. Endovasc Today. 2008;7(8):60-64.

Eroglu E, Yasim A, Ari M, et al. Mid-term results in the treatment of varicose veins with N-butyl cyanoacrylate. Phlebology. 2017;32(10):665-669.

Eroglu E, Yasim A. A randomised clinical trial comparing N-Butyl cyanoacrylate, radiofrequency ablation and endovenous laser ablation for the treatment of superficial venous incompetence: Two year follow up results. Eur J Vasc Endovasc Surg. 2018;56(4):553-560.

Fayyaz F, Vaghani V, Ekhator C, et al. Advancements in Varicose Vein Treatment: Anatomy, Pathophysiology, Minimally Invasive Techniques, Sclerotherapy, Patient Satisfaction, and Future Directions. Cureus. 2024;16(1):e51990.

Frullini A, Avezzi A. Sclerosing foam in the treatment of varicose veins and telangiectases: history and analysis of safety and complications. Dermatol Surg. 2002:28(1):11-15.

Fukaya E, O'Banion LA, Kiguchi M, et al. Evaluation and management of chronic venous insufficiency including venous leg ulcer. [UpToDate Web site]. 07/13/2023. Available at: https://www.uptodate.com/contents/evaluation-and-management-of-chronic-venous-insufficiency-including-venous-leg-ulcer. [via subscription only]. Accessed May 14, 2026.

Giannopoulos S, Rodriguez L, Chau M, et al. A systematic review of the outcomes of percutaneous treatment modalities for pathologic saphenous and perforating veins. J Vasc Surg Venous Lymphat Disord. 2022;10(5):1172-1183.

Gibson K, Ferris B. Cyanoacrylate closure of incompetent great, small and accessory saphenous veins without the use of post-procedure compression: Initial outcomes of a post-market evaluation of the VenaSeal System (the WAVES Study). Vascular. 2017;25(2):149-156.

Gibson K, Khilnani N, Schul M, et al. American College of Phlebology Guidelines - Treatment of refluxing accessory saphenous veins. Phlebology. 2017;32(7):448-452.

Gibson K, Morrison N, Kolluri R, et al. Twenty-four month results from a randomized trial of cyanoacrylate closure versus radiofrequency ablation for the treatment of incompetent great saphenous veins. J Vasc Surg Venous Lymphat Disord. 2018;6(5):606-613.

Gloviczki P, Bergan JJ, Menawat SS et al. Safety, feasibility and early efficacy of subfascial endoscopic perforator surgery: a preliminary report from the North American registry. J Vasc Surg.1997;25(1):94-105.

Gloviczki P, Camerota AJ, Dalsing MC, et al. 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. J Vasc Surg. 2011;53(5 Suppl):2S-48S.

Gloviczki P, Lawrence PF, Wasan SM, et al. The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine. J Vasc Surg Venous Lymphat Disord. 2024;12(1):101670.

Gloviczki P, Lawrence PF, Wasan SM, et al. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux: Endorsed by the Society for Vascular Medicine and the International Union of Phlebology. J Vasc Surg Venous Lymphat Disord. 2023;11(2):231-261.

Gohel MS, Barwell JR, Taylor M, et al. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial. BMJ. 2007;335(7610):83.

Hamel-Desnos C, Allaert FA. Liquid versus foam sclerotherapy. Phlebology. 2009;24(6):240-246.

Hamel-Desnos C, Nyamekye I, Chauzat B, et al. FOVELASS: A Randomised Trial of Endovenous Laser Ablation Versus Polidocanol Foam for Small Saphenous Vein Incompetence. Eur J Vasc Endovasc Surg. 2023; 65(3):415-423.

Ho VT, Adkar SS, Harris EJ. Systematic review and meta-analysis of management of incompetent perforators in patients with chronic venous insufficiency. J Vasc Surg Venous Lymphat Disord. 2022;10(4):955-964.

Hoggan BL, Cameron AL, Maddern GJ. Systematic review of endovenous laser therapy versus surgery for the treatment of saphenous varicose veins. Ann Vasc Surg. 2009; 23(2):277-287.

Holewijn S, van Eekeren RRJP, Vahl A, et al. Two-year results of a multicenter randomized controlled trial comparing Mechanochemical endovenous Ablation to RADiOfrequeNcy Ablation in the treatment of primary great saphenous vein incompetence (MARADONA trial). J Vasc Surg Venous Lymphat Disord. 2019;7(3):364-374.

Hirsch SA, Dillavou E. Options in the management of varicose veins, 2008. J Cardiovasc Surg (Torino). 2008;49(1):19-26.

Howard DP, Howard A, Kothari A, et al. The role of superficial venous surgery in the management of venous ulcers: a systematic review. Eur J Vasc Endovasc Surg. 2008;36(4):458-465.

Intersocietal Accreditation Commission. Available at: https://www.intersocietal.org/. Accessed May 14, 2026.

Jia X, Mowatt G, Burr J. Systematic review of foam sclerotherapy for varicose veins. Br J Surg. 2007;94(8):925-936.

Joh JH, Kim WS, Jung IM, Park KH, Lee T, Kang JM; Consensus Working Group. Consensus for the Treatment of Varicose Vein with Radiofrequency Ablation. Vasc Specialist Int. 2014;30(4):105-112.

Jones L, Braithwaite BD, Selwyn D, et al. Neovascularization is the principal cause of varicose vein recurrence: results of a randomized trial of stripping the long saphenous vein. Eur J Vasc Endovasc Surg.1996;12(4):442-445.

Kabnick LW, Scovell S. Overview of lower extremity chronic venous disease [UpToDate Web site]. 01/23/2023. Available at: https://www.uptodate.com/contents/overview-of-lower-extremity-chronic-venous-disease. [via subscription only]. Accessed May 14, 2026.

Kalra M, Gloviczki P, Noel AA, et al. Subfascial endoscopic perforator vein surgery in patients with post-thrombotic venous insufficiency – is it justified? Vasc Endovascular Surg. 2002;36(1):41-50.

Khilnani N, Grassi C, Kundu S, et al. Multi-society consensus quality improvement guidelines for the treatment of lower extremity superficial venous insufficiency with endovenous thermal ablation from the Society of Interventional Radiology, Cardiovascular Interventional Radiology Society of Europe, American College of Phlebology, and Canadian Interventional Radiology Society. J Vasc Interv Radiol. 2010;21(1):14-31.

Klem TM, Schnater JM, Schutte PR, et al. A randomized trial of cryo stripping versus conventional stripping of the great saphenous vein. J Vasc Surg. 2009;49(2):403-409.

Kundu S, Lurie F, Millward SF, et al. Recommended reporting standards for endovenous ablation for the treatment of venous insufficiency: joint statement of the American Venous Forum and the Society of Interventional Radiology. J Vasc Interv Radiol. 2007;18(9):1073-1080.

Lam YL, Lawson JA, Toonder IM, et al. Eight-year follow-up of a randomized clinical trial comparing ultrasound-guided foam sclerotherapy with surgical stripping of the great saphenous vein. Br J Surg. 2018;105(6):692-698.

Lane T, Bootun R, Dharmarajah B, et al. A multi-centre randomised controlled trial comparing radiofrequency and mechanical occlusion chemically assisted ablation of varicose veins - Final results of the Venefit versus Clarivein for varicose veins trial. Phlebology. 2017;32(2):89-98.

Laredo J, Lee BB, Neville RF. Endovenous thermal ablation of the anterior accessory great saphenous vein. Endovasc Today. 2010;9(3):36-39.

Leopardi D, Hoggan B, Fitridge R, et al. Systematic review of treatments for varicose veins. Ann Vasc Surg. 2009;23(2):264-276.

Lim AJM, Mohamed A, Leung C, Smith G, Chetter I, Carradice D. Editor's Choice - Five Year Follow Up of a Randomised Clinical Trial of Endovenous Laser Ablation versus Mechanochemical Ablation for Superficial Venous Incompetence (LAMA trial). Eur J Vasc Endovasc Surg. 2025;70(3):367-374.

Luebke T, Brunkwall J. Meta-analysis of subfascial endoscopic perforator vein surgery (SEPS) for chronic venous insufficiency. Phlebology. 2009;24(1):8-16.

Luebke T, Brunkwall J. Meta-analysis of transilluminated powered phlebectomy for superficial varicosities. J Cardiovasc Surg (Torino). 2008a;49(6):757-764.

Luebke T, Brunkwall J. Systematic review and meta-analysis of endovenous radiofrequency obliteration, endovenous laser therapy, and foam sclerotherapy for primary varicosis. J Cardiovasc Surg (Torino). 2008b;49(2):213-233.

Luebke T, Gawenda M, Heckencamp J, et al. Meta-analysis of endovenous radiofrequency obliteration of the great saphenous vein in primary varicosis. J Endovasc Ther. 2008;15(2):213-223.

Masuda E, Ozsvath K, Vossler J, et al. The 2020 appropriate use criteria for chronic lower extremity venous disease of the American Venous Forum, the Society for Vascular Surgery, the American Vein and Lymphatic Society, and the Society of Interventional Radiology. J Vasc Surg Venous Lymphat Disord. 2020;8(4):505-525.

Meissner MH, Gloviczki P, Bergan, et al. Primary chronic venous disorders. J Vasc Surg. 2007;46 Suppl S:54S-67S.

Menyhei G, Gyevnár Z, Arató E, Kelemen O, Kollár L . Conventional stripping versus cryostripping: a prospective randomised trial to compare improvement in quality of life and complications. Eur J Vasc Endovasc Surg. 2008;35(2):218-223.

Merchant RF, Pichot O. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg. 2005;42(3):502-509.

Michaels JA, Campbell WB, Brazier JE, et al. Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial). Health Technol Assess. 2006;10(13):1-196,iii-iv.

Mohamed AH, Leung C, Wallace T, et al. A Randomized Controlled Trial of Endovenous Laser Ablation Versus Mechanochemical Ablation With ClariVein in the Management of Superficial Venous Incompetence (LAMA Trial). Ann Surg. 2021;273(6):e188-e195.

Morrison N, Gibson K, McEnroe S, et al. Randomized trial comparing cyanoacrylate embolization and radiofrequency ablation for incompetent great saphenous veins (VeClose). J Vasc Surg. 2015;61(4):985-994.

Morrison N, Gibson K, Vasquez M, et al. VeClose trial 12-month outcomes of cyanoacrylate closure versus radiofrequency ablation for incompetent great saphenous veins. J Vasc Surg Venous Lymphat Disord. 2017;5(3):321-330.

Morrison N, Kolluri R, Vasquez M, et al. Comparison of cyanoacrylate closure and radiofrequency ablation for the treatment of incompetent great saphenous veins: 36-Month outcomes of the VeClose randomized controlled trial. Phlebology. 2019;34(6):380-390.

Myers KA, Jolley D. Factors affecting the risk of deep venous occlusion after ultrasound-guided sclerotherapy for varicose veins. Eur J Vasc Endovasc Surg. 2008;36(5):602-605.

National Institute for Health and Care Excellence (NICE). Endovenous laser treatment of the long saphenous vein. HealthTech Guidance HTG26. [NICE Web site]. March 2004. Available at: Overview | Endovenous laser treatment of the long saphenous vein | Guidance | NICE. Accessed May 14, 2026.

National Institute for Health and Care Excellence (NICE). Endovenous mechanochemical ablation for varicose veins; HealthTech Guidance HTG414. [NICE Web site]. May 2016. Available at: Overview | Endovenous mechanochemical ablation for varicose veins | Guidance | NICE. Accessed May 14, 2026.

National Institute for Health and Care Excellence (NICE). Radiofrequency ablation of varicose veins. HealthTech Guidance HTG2. [NICE Web site]. September 2003. Overview | Radiofrequency ablation of varicose veins | Guidance | NICE. Accessed May 14, 2026.

National Institute for Health and Care Excellence (NICE). Ultrasound-guided foam sclerotherapy for varicose veins. HealthTech Guidance HTG301. [NICE Web site]. February 2013. Available at: Overview | Ultrasound-guided foam sclerotherapy for varicose veins | Guidance | NICE Accessed May 14, 2026.

Nelzén O. Prospective study of safety, patient satisfaction and leg ulcer healing following saphenous and subfascial endoscopic perforator surgery. Br J Surg. 2000;87(1):86-91.

Nelzén O, Fransson I. True long-term healing and recurrence of venous leg ulcers following SEPS combined with superficial venous surgery: a prospective study. Eur J Vasc Endovasc Surg. 2007;34(5):605-612.

Nesbitt C, Bedenis R, Bhattacharya, Stansby G. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices. Cochrane Database Syst Rev. 2014 Jul 30:(7):CD005624.

Nicolaides A, Allegra C, Bergan J, et al. Management of chronic venous disorders of the lower limbs. Guidelines according to scientific evidence. Int Angiol. 2008;27(1):1-59.

Novitas Solutions, Inc. Local Coverage Article. A55229: Treatment of Chronic Venous Insufficiency of the Lower Extremities. [Novitas Solutions Web site]. Original: 11/08/2016. (Revised: 01/01/2026). Available at:
Article - Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities (A55229). Accessed May 14, 2026.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L34924: Treatment of Chronic Venous Insufficiency of the Lower Extremities. [Novitas Solutions Web site]. Original: 10/01/2015. (Revised: 12/27/2020). Available at: LCD - Treatment of Chronic Venous Insufficiency of the Lower Extremities (L34924). Accessed May 14, 2026.

O'Donnell TF, Jr. The present status of surgery of the superficial venous system in the management of venous ulcer and the evidence for the role of perforator interruption. J Vasc Surg. 2008;48(4):1044-1052.

O'Meara S, Cullum NA, Nelson EA. Compression for venous leg ulcers. Cochrane Database Syst Rev. 2009;1:CD000265.

Oud S, Alozai T, Lam YL, Ünlü Ç, Mooij M, Schreve MA. Long-term outcomes of mechanochemical ablation using the Clarivein device for the treatment of great saphenous vein incompetence. J Vasc Surg Venous Lymphat Disord. 2025;13(1):101967.

Ouvry P, Allaert FA, Desnos P, et al. Efficacy of polidocanol foam versus liquid in sclerotherapy of the great saphenous vein: a multicentre randomised controlled trial with a 2- year follow-up. Eur J Vasc Endovasc Surg. 2008;36(3):366-370.

Palm MD, Guiha IC, Goldman MP. Foam sclerotherapy for reticular veins and nontruncal varicose veins of the legs: a retrospective review of outcomes and adverse effects. Dermatol Surg. 2010;36:1026-1033.

Paravastu SC, Horne M, Dodd PD. Endovenous ablation therapy (laser or radiofrequency) or foam sclerotherapy versus conventional surgical repair for short saphenous varicose veins. Cochrane Database Syst Rev. 2016;11:CD010878.

Passman MA. Approach to treating symptomatic superficial venous insufficiency. [Up to Date Web site]. 01/09/2024. Available at: http://www.uptodate.com [via subscription only]. Accessed April 15, 2025.

Pierik EG, van Urk H, Hop WC, et al. Endoscopic versus open subfascial division of incompetent perforating veins in the treatment of venous leg ulceration: a randomized trial. J Vasc Surg. 1997;26(6):1049-1054.

Rabe E, Otto J, Schliephake D, et al. Efficacy and safety of great saphenous vein sclerotherapy using standardized polidocanol foam (ESAF): a randomised controlled multicentre clinical trial. Eur J Vasc Endovasc Surg. 2008;35(2):238-245.

Raju S, Neglen P. Clinical practice. Chronic venous insufficiency and varicose veins. N Engl J Med. 2009;360(22):2319-2327.

Rasmussen LH, Bjoern L, Lawaetz M, et al. Randomised clinical trial comparing endovenous laser ablation with stripping of the great saphenous vein: clinical outcome and recurrence after 2 years. Eur J Endovasc Surg. 2010;39(5):630-635.

Rasmussen LH, Lawaetz M, Bjoern L, Vennits B, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg. 2011;98(8):1079-1087.

Rass K, Frings N, Glowacki P, et al. Same site recurrence is more frequent after endovenous laser ablation compared with high ligation and stripping of the great saphenous vein: 5 year results of a randomized clinical trial (RELACS Study). Eur J Vasc Endovasc Surg. 2015;50(5):648-656.

Rutgers PH, Kitslaar PJ. Randomized trial of stripping versus high ligation combined with sclerotherapy in the treatment of the incompetent greater saphenous vein. Am J Surg. 1994;168(4):311-315.

Sato DT, Goff CD, Gregory RT, et al. Subfascial perforator vein ablation: comparison of open versus endoscopic techniques. J Endovasc Surg.1999;6(2):147-154.

Scovell S. Injection sclerotherapy techniques for the treatment of telangiectasias, reticular veins, and small varicose veins. [UpToDate Web site]. 01/03/2024. Available at: Injection sclerotherapy techniques for the treatment of telangiectasias, reticular veins, and small varicose veins - UpToDate [via subscription only]. Accessed May 14, 2026.

Society of Interventional Radiology (SIR). Position statement on endovenous ablation. [SIR Web site]. December 2003. Available at: http://www.scvir.org/clinical/cpg/SIR_venous_ablation_statement_Final2015.pdf. Accessed May 14, 2026.

Sparks SR, Ballard JL, Bergan JJ, et al. Early benefits of subfascial endoscopic perforator surgery (SEPS) in healing venous ulcers. Ann Vasc Surg.1997;11(4):367-373.

Stuart WP, Adam DJ, Allan PL, et al. Saphenous surgery does not correct perforator incompetence in the presence of deep venous reflux. J Vasc Surg.1998;28(5):834-838.

Stucker M, Kobus S, Altmeyer P, Reich-Schupke S. Review of published information on foam sclerotherapy. Dermatol Surg. 2010;36:983-992.

Tenbrook JA, Iafrati MD, O’Donnell TF et al. Systematic review of outcomes after surgical management of venous disease incorporating subfascial endoscopic perforator surgery. J Vasc Surg. 2004;39(3):583-589.

Theivacumar NS, Darwood R, Gough MJ. Neovascularisation and recurrence 2 years after varicose vein treatment for sapheno-femoral and great saphenous vein reflux: a comparison of surgery and endovenous laser ablation. Eur J Vasc Endovasc Surg. 2009; 38(2):203-207.

Thierrens NDE, Holewijn S, Vissers WHPM, Werson DAB, de Vries JPPM, Reijnen MMPJ. Five year outcomes of mechanochemical ablation of primary great saphenous vein incompetence. Phlebology. 2019;0(0)1-7.

Tisi PV, Beverley C, Rees A. Injection sclerotherapy for varicose veins. Cochrane Database Syst Rev. 2006;(4):CD001732.

Todd KL, Wright D. The VANISH-2 study: a randomized, blinded, multicenter study to evaluate the efficacy and safety of polidocanol endovenous microfoam 0.5% and 1.0% compared with placebo for the treatment of saphenofemoral junction incompetence. Phlebology. 2014;29(9):608-618.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. ClariVein infusion catheter. 510(k) summary. [FDA Web site]. 03/20/2008. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf7/K071468.pdf. Accessed May 14, 2026.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Erbe Erbokryo cryosurgical unit. 510(k) summary. [FDA Web site]. 07/27/2005. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf5/K051509.pdf. Accessed May 14, 2026.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Asclera (polidocanol). Approval letter. [FDA Web site]. 03/30/2010. Available at:http://www.accessdata.fda.gov/drugsatfda_docs/appletter/2010/021201s000ltr.pdf. Accessed May 14, 2026.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Asclera (polidocanol) injection, for intravenous use. Prescribing information. [FDA Web site]. March 2010. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021201lbl.pdf. Accessed May 14, 2026.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Sotradecol injection (sodium tetradecyl sulfate injection). Approval letter. [FDA Web site]. 11/12/2004. Available at:http://www.accessdata.fda.gov/drugsatfda_docs/appletter/2004/40541ltr.pdf. Accessed May 14, 2026.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. TriVex System. 510(k) Summary. [FDA Web site]. 10/29/2003. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf3/K032387.pdf. Last accessed May 14, 2026.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. KAVS catheter [501K Summary]. Richter and Rothe AG. 10/03/2005. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf5/K052844.pdf. Accessed May 14, 2026.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Varithena Summary Review. [FDA Web site]. 11/14/2013. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/nda/2013/205098Orig1s000SumR.pdf. Accessed May 14, 2026.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. VenaSeal Closure System - P140018. Approval Letter. [FDA Web site]. 02/20/2015. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf14/P140018a.pdf. Accessed May 14, 2026.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. VNUS Closure System. 510(k) Premarket Notification. [FDA Web site]. 10/21/2016. Available at: 510(k) Premarket Notification Accessed May 14, 2026.

Vahaaho S, Halmesmaki K, Alback A, et al. Five-year follow-up of a randomized clinical trial comparing open surgery, foam sclerotherapy and endovenous laser ablation for great saphenous varicose veins. Br J Surg. 2018;105(6):686-691.

Vahaaho S, Mahmoud O, Halmesmäki K, et al. Randomized clinical trial of mechanochemical and endovenous thermal ablation of great saphenous varicose veins. Br J Surg. 2019;106(5):548-554.

Van Gent WB, Hop WC, van Praag MC, et al. Conservative versus surgical treatment of venous leg ulcers: a prospective, randomized, multicenter trial. J Vasc Surg. 2006;44(3):563-571.

Van der Velden SK, Biemans AA, De Maeseneer MG, et al. Five-year results of a randomized clinical trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins. Br J Surg. 2015;102(10):1184-1194.

Vasquez, MA, Rabe E, McLafferty RB et al. Revision of the venous clinical severity score: Venous outcomes consensus statement: Special communication of the American Venous Forum Ad Hoc Outcomes Working Group. J Vasc Surg. 2010;52(5):1387-1396.

Vasquez M, Gasparis AP; Varithena® 017 Investigator Group. A multicenter, randomized, placebo-controlled trial of endovenous thermal ablation with or without polidocanol endovenous microfoam treatment in patients with great saphenous vein incompetence and visible varicosities. Phlebology. 2017;32(4): 272-281.

Viljamaa J, Firoozi K, Venermo M, et al. A study protocol for comparing the treatment of varicose tributaries either concomitantly with or separately from endovenous laser ablation of the incompetent saphenous trunk (the FinnTrunk Study). A multicenter parallel-group randomized controlled study. PLoS One. 2023;18(5):e0285823.

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.

Zhao ZY, Zhang XJ, Li JH, Huang M. Comparison of high ligation and stripping of the great saphenous vein combined with foam sclerotherapy versus conventional surgery for the treatment of superficial venous varicosities of the lower extremity. Int J Clin Exp Med. 2015;8(5):7843-7848.

Coding

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785

THE FOLLOWING CODE IS USED TO REPRESENT TRANSILLUMINATED POWERED PHLEBECTOMY (e.g., TriVex system):

37799

THE FOLLOWING CODE IS USED TO REPRESENT STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY, FEWER THAN 10 INCISIONS:

37799

THE FOLLOWING CODE IS USED TO REPRESENT VASCULAR ENDOSCOPY, SURGICAL, WITH LIGATION OF PERFORATOR VEINS, SUBFASCIAL (SEPS)

37799

EXPERIMENTAL/INVESTIGATIONAL

0524T

THE FOLLOWING CODE IS USED TO REPRESENT ENDOVENOUS CRYOABLATION OF ANY VEIN:

37799

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

MEDICALLY NECESSARY

PROCEDURE CODES (36465, 36466, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799 ) ARE CONSIDERED MEDICALLY NECESSARY FOR THE FOLLOWING INDICATIONS:

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

I80.241 Phlebitis and thrombophlebitis of right peroneal vein

I80.242 Phlebitis and thrombophlebitis of left peroneal vein

I80.243 Phlebitis and thrombophlebitis of peroneal vein, bilateral

I80.249 Phlebitis and thrombophlebitis of unspecified peroneal vein

I80.251 Phlebitis and thrombophlebitis of right calf muscular vein

I80.252 Phlebitis and thrombophlebitis of left calf muscular vein

I80.253 Phlebitis and thrombophlebitis of calf muscular vein, bilateral

I80.259 Phlebitis and thrombophlebitis of unspecified calf muscular vein

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

I83.211 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 extremities with pain

I83.812 Varicose veins of left lower extremities with pain

I83.813 Varicose veins of bilateral lower extremities with pain

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

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

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

I87.2 Venous insufficiency (chronic) (peripheral)

I87.311 Chronic venous hypertension (idiopathic) with ulcer of right lower extremity

I87.312 Chronic venous hypertension (idiopathic) with ulcer of left lower extremity

I87.313 Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity

I87.321 Chronic venous hypertension (idiopathic) with inflammation of right lower extremity

I87.322 Chronic venous hypertension (idiopathic) with inflammation of left lower extremity

I87.323 Chronic venous hypertension (idiopathic) with inflammation of bilateral lower extremity

I87.331 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity

I87.332 Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity

I87.333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity

I87.391 Chronic venous hypertension (idiopathic) with other complications of right lower extremity

I87.392 Chronic venous hypertension (idiopathic) with other complications of left lower extremity

I87.393 Chronic venous hypertension (idiopathic) with other complications of bilateral lower extremity

PROCEDURE CODE (36468) IS CONSIDERED MEDICALLY NECESSARY FOR THE FOLLOWING INDICATIONS:

D69.8 Other specified hemorrhagic conditions

I78.0 Hereditary hemorrhagic telangiectasia

R58 Hemorrhage, not elsewhere classified

PROCEDURE CODES (36465, 36466, 36470, 36471) ARE CONSIDERED MEDICALLY NECESSARY FOR THE FOLLOWING INDICATION:

Q27.8 Other specified congenital malformations of peripheral vascular system

HCPCS Level II Code Number(s)

MEDICALLY NECESSARY:

S2202 Echosclerotherapy

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

The following CPT codes should be used to report sclerotherapy for treatment of non-truncal varicose veins and injection of physician compounded foam in any vein: 36470, 36471. CPT codes 36465 and 36466 should not be used for treatment of symptomatic varicose tributaries, or to report injection of physician compounded foam. CPT codes 36465, 35466 are used to report non-compounded foam for the treatment of truncal veins only.

Cross Reference

Policy History

Revisions From MA11.011l:

07/08/2026	This policy has been reviewed and reissued to communicate the Company's continuing position on treatment of varicose veins of the lower extremities and perforator vein incompetence.
01/01/2026	This policy has been identified for the CPT code update, effective 01/01/2026. The following CPT code has been deleted from this policy: 37500 The following NOC code has been added to this policy: 37799

Revisions From MA11.001k:

07/28/2025

This version of the policy will become effective 07/28/2025.

Language was updated in the Policy statement to clarify "TIPP" by adding ("the TriVex system").

Medically necessary criteria for the Venous Clinical Severity Score (VCSS) in treatment of great/small saphenous vein was revised from less than to greater than 6.

The following NOC CPT was added to represent endovenous cryoablation: 37799 (Experimental/Investigational).

The Experimental/investigational policy statement for ambulatory hook and stab avulsion or TIPP of Perforator, Great or Small Saphenous or Accessory Saphenous Vein, was removed.

Revisions From MA11.001j:

01/13/2025

Retroactively effective 03/11/2021

This version of the policy published on 01/13/2025 with a retroactively effective date of 03/11/2021.

Revisions were updated in accordance with the Centers for Medicare & Medicaid (CMS) to allow coverage of sclerotherapy, including ultrasound-guided foam sclerotherapy, and liquid sclerotherapy and cyanoacrylate adhesive in the treatment of saphenous veins.

Additional medically necessary coverage statements were added for bulbous varicosities and venous malformations, and telangiectasia with the presence of spontaneous and/or traumatic venous hemorrhage. Experimental/investigational coverage statements were added for catheter-assisted vein sclerotherapy with balloon isolation.

The coverage position for the following code was revised from cosmetic to medically necessary: 36468. The coverage position for the following codes was revised from experimental/Investigational to medically necessary: 36482, 36483. The coverage position for the following code was revised from Not Medically Necessary to Medically Necessary: S2202 Echosclerotherapy.

The following NOC code was added to the policy to represent stab phlebectomy fewer than 10 incisions: 37799 (Medically Necessary)

A coding/billing requirement to provide direction on correct coding for sclerotherapy treatment of tributaries and physician compounded foam was added.

Revisions From MA11.011i:

01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
10/01/2019	This policy has been identified for the ICD-10 codes update, effective 10/01/2019. The following ICD-10 codes has been added to this policy: I80.241 Phlebitis and thrombophlebitis of right peroneal vein I80.242 Phlebitis and thrombophlebitis of left peroneal vein I80.243 Phlebitis and thrombophlebitis of peroneal vein, bilateral I80.249 Phlebitis and thrombophlebitis of unspecified peroneal vein I80.251 Phlebitis and thrombophlebitis of right calf muscular vein I80.252 Phlebitis and thrombophlebitis of left calf muscular vein I80.253 Phlebitis and thrombophlebitis of calf muscular vein, bilateral I80.259 Phlebitis and thrombophlebitis of unspecified calf muscular vein

01/01/2024

Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.

10/01/2019

This policy has been identified for the ICD-10 codes update, effective 10/01/2019.

The following ICD-10 codes has been added to this policy:

I80.241 Phlebitis and thrombophlebitis of right peroneal vein

I80.242 Phlebitis and thrombophlebitis of left peroneal vein

I80.243 Phlebitis and thrombophlebitis of peroneal vein, bilateral

I80.249 Phlebitis and thrombophlebitis of unspecified peroneal vein

I80.251 Phlebitis and thrombophlebitis of right calf muscular vein

I80.252 Phlebitis and thrombophlebitis of left calf muscular vein

I80.253 Phlebitis and thrombophlebitis of calf muscular vein, bilateral

I80.259 Phlebitis and thrombophlebitis of unspecified calf muscular vein

Revisions From MA11.001h:

04/01/2019

This 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 MA11.011g:

01/01/2019

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

Revisions From MA11.001f:

03/27/2018

This 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. Sclerotherapy is not effective for these veins.

Revisions from MA11.001e:

01/01/2018

This 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

Revisions from MA11.001d:

10/01/2017

This version of the policy will become effective 10/01/2017.

The following ICD-10 CM narratives have been revised in this policy:

I83.811:

FROM: Varicose veins of right lower extremities with pain
TO: Varicose veins of right lower extremity with pain

I83.812:

FROM: Varicose veins of left lower extremities with pain
TO: Varicose veins of left lower extremity with pain

I83.819

FROM: Varicose veins of unspecified lower extremities with pain
TO: Varicose veins of unspecified lower extremity with pain

I83.891

FROM: Varicose veins of right lower extremities with other complications
TO: Varicose veins of right lower extremity with other complications

I83.892

FROM: Varicose veins of left lower extremities with other complications
TO: Varicose veins of left lower extremity with other complications

I83.899

FROM: Varicose veins of unspecified lower extremities with other complications
TO: Varicose veins of unspecified lower extremity with other complications

Revisions from MA11.001c:

01/01/2017

This policy will become effective 01/01/2017.

The following NOC code has been removed from this policy and is replaced by the following CPT codes:

REMOVED: 37799

REPLACED WITH: 36473, 36474

The following CPT narratives have been revised in this policy for the following codes:

36476, 36479

Revisions from MA11.001b:

09/07/2016

This version of the policy will become effective on 09/07/2016. This policy has been updated to communicate the Company’s continuing position on Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence. The intent of the policy is unchanged; however, ICD-10 Coding has been revised.

Revisions from MA11.001a:

01/20/2016

This policy will become effective 02/10/2016.
Policy revised to communicate coverage for Greater or Lesser Saphenous veins, Accessory saphenous veins, and Perforator veins. Not medically necessary and experimental/investigational statements are also revised.

Revisions from MA11.001:

01/01/2015

This policy will become effective 01/01/2016.

This is a new policy.

Version Effective Date:

1/1/2026

Version Issued Date:

1/2/2026

Version Reissued Date:

7/8/2026

Medicare Advantage

Medical Policy

Notification

Policy

Guidelines

Description

References

Coding

CPT Procedure Code Number(s)

ICD - 10 Procedure Code Number(s)

ICD - 10 Diagnosis Code Number(s)

HCPCS Level II Code Number(s)

Revenue Code Number(s)

MPMiscCodesNarrativesPub​

Coding and Billing Requirements

Cross Reference

Policy History

MPMiscCodesNarrativesPub