UPMC Health Plan POLICY AND PROCEDURE MANUAL POLICY NUMBER: PAY.066 REVISION DATE: 07/13 ANNUAL APPROVAL DATE: 09/13 PAGE NUMBER: 1 of 7 SUBJECT: INDEX TITLE: ORIGINAL DATE: Treatment of Varicose Veins Medical Management August 2008 This policy applies to the following lines of business: (Check those that apply.) COMMERCIAL CMS-MA DPW-MA HMO ( ) OH ( ) Health Choices /PH (X) PPO ( ) WV ( ) Health Choices/BH ( ) Fully Insured ( ) PA ( ) All ( ) Self-funded/ASO ( ) All (X) WORK PARTNERS Indiv. Product ( ) HMO (X) Commercial WC ( ) All (X) PPO (X) Disability Svcs/TPA ( ) CSNP (X) Health Promotion ( ) PID-CHIP CHIP (X) DSNP (X) All ( ) ISNP (X) Part D ( ) All ( ) I. ANCILLARY UPMC Dental Adv. ( ) UPMC Vision Adv. ( ) COBRA ( ) FSA ( ) HSA ( ) HRA ( ) HIA ( ) All ( ) POLICY It is the policy of UPMC Insurance Services Division to recognize that treatment for varicose veins for non-cosmetic purposes is consistent with good medical practice when medically necessary and when performed according to the clinical indications as described in this policy. Treatments for varicose veins will be covered when conducted according to the standards established by UPMC Insurance Services Division and the member’s specific benefit plan. II. DEFINITIONS Laser Ablation: the removal of a vein or artery using a laser. Ligation: tying off a large vein. Phlebectomy (also known as stab or ambulatory phlebectomy): is a minimally invasive technique for surgical removal of varicose veins through tiny incisions in the skin overlaying the vein. Sclerotherapy: the injection of a sclerotic solution to treat varicose veins. Proprietary and Confidential Information of UPMC Health Plan © 2013 UPMC All Rights Reserved POLICY NUMBER: PAY.066 REVISION DATE: 07/13 ANNUAL APPROVAL DATE: 09/13 PAGE NUMBER: 2 of 7 Stripping: the removal of a vein through incision into the skin. Varicose Veins: veins that have become enlarged and gnarled and are unable to prevent blood reflux. Varix: an enlarged and tortuous vein or artery. III. PURPOSE The purpose of this policy is to outline the indications and limitations for treatment of varicose veins in order to distinguish between cosmetic treatments versus medical necessity. IV. SCOPE This policy applies to various UPMC Insurance Services Division departments as indicated by the Benefit and Reimbursement Committee. These include but are not limited to: Medical Management, Benefit Configuration and Claims Departments. V. PROCEDURE A. Medical Description The treatment of varicose veins is intended to relieve symptoms and manage complications to prevent further health issues. Varicose veins are veins that have become enlarged and gnarled, and are usually found in the lower extremities, and protrude from the skin surface. In addition to the pain and discomfort experienced, varicose veins may lead to serious complications including pulmonary embolism, thrombophlebitis, hemorrhage, and venous insufficiency and ulceration. To manage varicose veins, there are conservative treatments for mild symptoms that include periodic leg elevation, mild exercise and compressive stockings. For severe varicosities and progressive, long-standing conditions, there are several treatment options. This policy addresses surgical treatment, radiofrequency endovenous occlusion (ERFA) & endovenous laser ablation, injection/compression sclerotherapy and subfascial endoscopic perforator vein surgery (SEPS). Telangiectasias, or spider veins, which have a web-like appearance on the surface of the skin, are viewed as cosmetic and not covered by this policy. Proprietary and Confidential Information of UPMC Health Plan © 2013 UPMC All Rights Reserved POLICY NUMBER: PAY.066 REVISION DATE: 07/13 ANNUAL APPROVAL DATE: 09/13 PAGE NUMBER: 3 of 7 B. Indications for symptomatic varicose vein treatment: 1. Surgical treatment, sclerotherapy, radiofrequency ablation or laser ablation, and subfascial endoscopic perforator vein surgery (SEPS) for the treatment of varicose veins of the legs are eligible for payment for those members who meet the following criteria: 1) A three month trial of supportive therapy ordered by the treating physician including support/compression hose, leg elevation, weight reduction and mild exercise where appropriate. Compression stockings are defined as graduated elasticized compression stockings. Use of non-graduated compression garments such as support pantyhose does not fulfill this requirement. 2) Duplex studies of the venous system performed by an accredited vascular technician that fully defines the anatomy, size and tortuosity of the greater and lesser saphenous vein, superficial venous segments and perforators. These studies must demonstrate both of the following:  Absence of deep venous thrombosis  Greater and /or lesser saphenous vein valvular incompetence/reflux that correlates with the patient’s symptoms 3) Any ONE of the following:  Pain, cramping, aching, itching or burning in the extremity substantial enough to impair mobility or activities of daily living  The veins are demonstrable (bulging) above the surface of the skin  Recurrent superficial phlebitis  Non-healing skin ulceration of the leg  Refractory dependent edema or other complications from venous stasis such as dermatitis  Hemorrhage from a ruptured varix *NOTE: Lack of patient compliance with compression stockings does not support the need for intervention without documentation of other failed conservative treatments as well. 2. Sclerotherapy (compression) – in addition to the general criteria, when injecting varicose veins with sclerosing solution, ALL of the following criteria must also be met:  There is no sapheno-femoral insufficiency, incompetency or occlusion of the deep veins  The varicosities are at least 3mm in size.  Sclerotherapy may be covered as part of a combination procedure with surgical ligation and excision. Proprietary and Confidential Information of UPMC Health Plan © 2013 UPMC All Rights Reserved POLICY NUMBER: PAY.066 REVISION DATE: 07/13 ANNUAL APPROVAL DATE: 09/13 PAGE NUMBER: 4 of 7 3. Radiofrequency endovenous occlusion (ERFA) and endovenous laser ablation(EVLA) - in addition to the general criteria above, ALL of the following must be met:  Patient’s anatomy is amenable to laser or radiofrequency catheter with absence of vein tortuosity that would impair catheter advancement.  Maximum saphenous vein diameter is 12 mm (only for ERFA).  Non-aneurysmal saphenous vein(s). 4. Stab or ambulatory phlebectomy may be medically necessary when the indications listed above are met for persons whose symptoms and functional problems are attributable only to the secondary, smaller vessels. 5. SEPS for identified perforator incompetence, may be medically necessary for the treatment of patients who meet the general indications for varicose vein surgical stripping listed above as demonstrated by chronic venous insufficiency secondary to primary valvular incompetence of superficial and perforating veins, with or without deep venous incompetence, and when conservative treatment has failed. C. Limitations       Injection of a sclerosing solution into telangiectasias, (spider veins, hemangiomata and angiomata) regardless of the anatomical site (leg, face, trunk) is considered cosmetic and not covered by UPMC HealthPlan. When performing ligation and division of the long saphenous vein at the saphenofemoral junction, placement of a percutaneous suture instead of a true ligation will be denied. Doppler ultrasound or duplex scans will be required prior to the treatment to characterize the venous anatomy and pathology (can demonstrate both the absence of deep venous thrombosis and greater and/or lesser saphenous vein valvular incompetence/reflux that correlates with the patient’s symptoms). Ultrasound or duplex scans to guide or monitor during sclerotherapy will not be covered. All methods of treatment for asymptomatic varicose veins, superficial telangiectasias, spider veins, and other superficial vascular anomalies including sclerotherapy, photothermal sclerosis (Vasculight®) and all forms of laser treatments are considered cosmetic and not covered. Non-compressive sclerotherapy is also not covered because this treatment method has not been shown to be effective in providing long-term obliteration of the incompetent veins. Sclerotherapy, with or without ultrasound guidance, is considered ineffective for treatment of the sapheno-femoral junction or the saphenous veins, and has not been proven effective in treating larger veins, nor has it Proprietary and Confidential Information of UPMC Health Plan © 2013 UPMC All Rights Reserved POLICY NUMBER: PAY.066 REVISION DATE: 07/13 ANNUAL APPROVAL DATE: 09/13 PAGE NUMBER: 5 of 7   been shown to be effective for members with reflux at the saphenofemoral or saphenopopliteal junctions. SEPS for the treatment of post-thrombotic syndrome or varicose veins without identified perforator incompetence is considered experimental/investigational because the effectiveness for these indications has not been established. Transdermal laser treatment of large symptomatic varicose veins is not covered. D. Variations N/A E. Quality Audit Quality Audit monitors policy compliance and/or billing accuracy at the request of the UPMC Insurance Services Division’s Technology Assessment Committee or the Benefits Reimbursement Committee. F. Records Retention Records Retention for documents, regardless of medium, are provided within the UPMC Health System Policy for Records Retention, Management and Retirement, and as indicated in the UPMC Insurance Services Division Policy and Procedure for Records Retention. G. References 1. Novitas Solutions, LCD 27539 – treatment of Varicose Veins of the Lower Extremities, 4/2/12. http://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?LCDId=27539&ContrId=170&ver=55&ContrVer=2&CntrctrSelecte d=170*2&Cntrctr=170&name=Novitas+Solutions%2c+Inc.+(12502%2c+MAC++Part+B)&s=45&DocType=All&bc=AggAAAIAAAAAAA%3d%3d& 2. Ultrasound-guided Sclerotherapy for the Treatment of Varicose Veins. ECRI Institute; Hotline Response. Published: 07/27/2011. https://mebmers2.ecri.org/Components/Hotline/Pages/10087.aspx 3. Endovenous Radio-frequency ablation (VNUS Closure System) for the Treatment of Varicose Veins. ECRI Institute: Evidence Reports. Published 08/24/2006. https://members2.ecri.org/Components/EvidenceReports/Pages/6889.aspx 4. Biemans A, Kockaert M, Akkersdijk G, et al. Comparing endovenous laser ablation, foam sclerotherapy, and conventional surgery for great saphenous varicose veins. J Vasc Surg. 2013 June 13; [Epub ahead of print] http://dx.doi.org/10.1016/j.jvs.2012.12.074.(http://www.sciencedirect.com/scienc e/article/pii/S074152141300133X) Proprietary and Confidential Information of UPMC Health Plan © 2013 UPMC All Rights Reserved POLICY NUMBER: PAY.066 REVISION DATE: 07/13 ANNUAL APPROVAL DATE: 09/13 PAGE NUMBER: 6 of 7 5. Wright N, Fitridge R. Varicose Veins: Natural history, assessment and management. Aust Fam Physician. 2013 June; 42(6):380-384. http://www.racgp.org.au/afp2013//june/varicose-veins/ Proprietary and Confidential Information of UPMC Health Plan © 2013 UPMC All Rights Reserved POLICY NUMBER: PAY.066 REVISION DATE: 07/13 ANNUAL APPROVAL DATE: 09/13 PAGE NUMBER: 7 of 7 Disclaimer: UPMC Health Plan medical payment and prior authorization policies do not constitute medical advice and are not intended to govern or otherwise influence the practice of medicine. The policies constitute only the reimbursement and coverage guidelines of UPMC Health Plan and its affiliated managed care entities. Coverage for services varies for individual members in accordance with the terms and conditions of applicable Certificates of Coverage, Summary Plan Descriptions, or contracts with governing regulatory agencies. UPMC Health Plan reserves the right to review and update the medical payment and prior authorization guidelines in its sole discretion. Notice of such changes, if necessary, shall be provided in accordance with the terms and conditions of provider agreements and any applicable laws or regulations. These policies are the proprietary information of UPMC Health Plan. Any sale, copying, or dissemination of said policies is prohibited. Proprietary and Confidential Information of UPMC Health Plan © 2013 UPMC All Rights Reserved