Varicose Vein Procedure Guideline (0100‐GL‐DEPT‐0022‐HS) Prior authorization does not guarantee payment. Coverage of services is based on member eligibility and member’s benefits per the medical certificate of coverage at the time services are rendered. Physicians Plus considers varicose vein procedures to be a medically necessary covered benefit with a prior authorization that meets criteria and is performed as an outpatient by a participating provider. Utilization Management (UM) staff collects relevant clinical information from the treating physician and/or practitioner to support accurate and appropriate UM determinations based on benefit coverage and medical necessity. Sources of member specific clinical information includes but is not limited to: • Office and hospital records • A history of the presenting problem • Clinical exams • Diagnostic test results • Treatment plans and progress notes • Consults with the treating provider • Evaluations from other health care practitioners and providers • Photos • Operative and pathology reports • Criteria language related to the request • Certificate language for benefits for the requested service or procedure • Patient characteristics and information • Letter of medical necessity from provider A. The following criteria must be met for approval of surgical treatment: CPT codes: 37700, 37718, 37722, 37735, 37760, 37761 37765, 37766, 37780, 37785 Sclerotherapy CPT codes: 36470, 36471 1. A 3‐month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, compressive therapy, and avoidance of prolonged immobility where appropriate, has failed, AND 2. The patient is symptomatic with varicose veins of at least 3 mm and has one or more of the following: • Pain, aching cramping burning itching and or swelling during activity or after prolonged • • • • • standing severe enough to impair mobility. Recurrent episodes of superficial phlebitis. Non‐healing skin ulceration. Bleeding from a varicosity. Stasis dermatitis. Refractory dependent edema. 3. The treatment of spider veins/telangiectasis (36468) will be considered medically necessary only if there is associated hemorrhage (IDC‐9 459.0). 4. If sclerotherapy is used with endovenous ablation, it may be covered if the criteria for reasonable and necessary as described in this guideline are met. This applies to varicose veins in the same leg as the endovenous ablation done on the day of the ablation or within the first 6 months after the ablation. Any need for sclerotherapy to treat residual varicose veins after this period would then need to have an additional 3 months of conservative treatment and meet the other criteria as outlined above. B. Indications for ERFA or laser ablation (CPT codes 36475, 36476, 36478, 36479): In addition to the above (see A), the patient's anatomy and clinical condition are amenable to the proposed treatment including ALL of the following: • Absence of aneurysm in the target segment. • Maximum vein diameter of 20 mm for ERFA or 30 mm for laser ablation. • Absence of thrombosis or vein tortuosity, which would impair catheter advancement. • The absence of significant peripheral arterial diseases. C. Limitations for ERFA and laser ablation: • • • • • • • • ERFA and laser ablation are covered only for the treatment of symptomatic varicosities of the lesser or greater saphenous veins and their tributaries which have failed 3 months of conservative therapy. Intra‐operative ultrasound guidance is not separately payable with ERFA, laser ablation. The treatment of asymptomatic varicose veins, or symptomatic varicose veins without a 3‐ month trial of conservative measures, by any technique, will be considered cosmetic and therefore not covered. The treatment of spider veins or superficial telangiectasis by any technique is also considered cosmetic, and therefore not covered unless there is associated bleeding. Coverage is only for devices specifically FDA‐approved for these procedures. One pre‐operative Doppler ultrasound study or duplex scan will be covered. Post‐procedure Doppler ultrasound studies will be allowed if medically necessary. Physicians Plus considers one post‐procedure Doppler ultrasound within the first week medically necessary to rule out DVT. The stab phlebectomy of the same vein performed on the same day as endovenous radiofrequency or laser ablation may be covered if the criteria for reasonable and necessary as described in this LCD are met. Number of treatments will be limited to 3 visits (one surgical or endovenous ablation session + 2 sessions for sclerotherapy). If 2 legs are involved and meet criteria, a total of 4 visits may be allowed (one surgical or endovenous ablation session per leg + 2 sessions for sclerotherapy). The treatment of asymptomatic veins with endoluminal ablation or sclerotherapy is not considered medically reasonable and necessary. If it is determined on review that the varicose veins were asymptomatic, the claim will be denied as a noncovered (cosmetic) procedure. REFERENCES: Treatment of Varicose Veins of the Lower Extremities (L30143) http://www.wpsmedicare.com/part_b/policy/active/local/130143_gsurg041.shtml Silberzweig JE, Funaki BS, Ray CE Jr, Burke CT, Kinney TB, Kostelic JK, Loesberg A, Lorenz JM, Mansour MA, Millward SF, Nemcek AA Jr, Owens CA, Reinhart RD, Vatakencherry G, Expert Panel on Interventional Radiology. ACR Appropriateness Criteria® treatment of lower‐extremity venous insufficiency. [online publication]. Reston (VA): American College of Radiology (ACR); 2009. CPT/HCPCS Codes 36468 SINGLE OR MULTIPLE INJECTIONS OF SCLEROSING SOLUTIONS, SPIDER VEINS (TELANGIECTASIA); LIMB OR TRUNK 36470 INJECTION OF SCLEROSING SOLUTION; SINGLE VEIN 36471 INJECTION OF SCLEROSING SOLUTION; MULTIPLE VEINS, SAME LEG 36475 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED 36476 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; SECOND AND SUBSEQUENT VEINS TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 36478 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; FIRST VEIN TREATED 36479 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; SECOND AND SUBSEQUENT VEINS TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 37500 VASCULAR ENDOSCOPY, SURGICAL, WITH LIGATION OF PERFORATOR VEINS, SUBFASCIAL (SEPS) 37700 LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS 37718 LIGATION, DIVISION, AND STRIPPING, SHORT SAPHENOUS VEIN 37722 LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW 37735 LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG OR SHORT SAPHENOUS VEINS WITH RADICAL EXCISION OF ULCER AND SKIN GRAFT AND/OR INTERRUPTION OF COMMUNICATING VEINS OF LOWER LEG, WITH EXCISION OF DEEP FASCIA 37760 LIGATION OF PERFORATOR VEINS, SUBFASCIAL, RADICAL (LINTON TYPE), INCLUDING SKIN GRAFT, WHEN PERFORMED, OPEN,1 LEG 37761 LIGATION OF PERFORATOR VEIN(S), SUBFASCIAL, OPEN, INCLUDING ULTRASOUND GUIDANCE, WHEN PERFORMED, 1 LEG 37765 STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS 37766 STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS 37780 LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE) 37785 LIGATION, DIVISION, AND/OR EXCISION OF VARICOSE VEIN CLUSTER(S), 1 LEG 37799 UNLISTED PROCEDURE, VASCULAR SURGERY 93965 NONINVASIVE PHYSIOLOGIC STUDIES OF EXTREMITY VEINS, COMPLETE BILATERAL STUDY (EG, DOPPLER WAVEFORM ANALYSIS WITH RESPONSES TO COMPRESSION AND OTHER MANEUVERS, PHLEBORHEOGRAPHY, IMPEDANCE PLETHYSMOGRAPHY) 93970 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY 93971 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY Guideline Last Updated: January 31, 2012