Sclerotherapy (Liquid or Microfoam)
Sclerotherapy may be considered medically necessary for the treatment of the small saphenous veins or saphenous tributaries, including accessory saphenous veins when ALL of the following criteria are met:
- Related incompetent superficial system veins (reflux) proximal to the incompetent vein to be treated either have been or are being treated concurrently; and
- CEAP Class C3-C6; and
- ALL of the general medically necessary criteria above are met.
Sclerotherapy performed on the small saphenous veins or saphenous tributaries (including saphenous veins) not meeting the criteria above will be considered cosmetic.
Non-covered
Sclerotherapy (liquid or microfoam) of the great saphenous vein and perforator veins is considered experimental/investigational and therefore non-covered due to lack of supporting scientific evidence.
Sclerotherapy (liquid or microfoam) of the following veins is considered cosmetic and therefore non- covered;
- Small veins less than five (5) mm in diameter; or
- Superficial reticular veins and/or telangiectasia veins (spider veins).
Coverage for sclerotherapy (liquid or microfoam) for these indications is limited to a maximum of three (3) sclerotherapy treatment sessions per leg: three (3) treatment sessions for the right leg and three (3) sessions for the left leg. A total of six (6) sessions may be authorized to treat these veins without additional clinical documentation, when performed within 12 months of the initial invasive varicose vein procedure.
- The number of medically necessary sclerotherapy injection sessions varies with the number of anatomical areas that have to be injected, as well as the response to each injection.
- Usually one (1) to three (3) injections is necessary to obliterate any vessel, and 10 to 40 vessels, or a set of up to a maximum of 20 injections in each leg, may be treated in any one (1) session.
- Requests for additional sclerotherapy sessions are subject to medical necessity review.
Requests for additional sclerotherapy (liquid or microfoam) treatment, extending beyond the maximum three (3) treatment sessions per leg, may be considered medically necessary when ALL of the following additional criteria have been met.
- Additional documentation confirms persistence of symptoms despite prior invasive treatment; and
- Doppler or Duplex reports and/or standing photographs confirm persistent veins at least five (5) mm in diameter; and
- Evidence of a clearly defined treatment plan including the procedure codes for the planned intervention.
Requests for treatment sessions extending beyond one year (12 months) from the initial invasive treatment session may be similarly subject to a new medical necessity review.
Ultrasound or duplex scanning may be considered medically necessary when initially performed to determine the extent and configuration of varicose veins. However, ultrasound or radiologically guided or monitoring techniques are considered not medically necessary when performed solely to guide the needle or introduce the sclerosant into the varicose veins.
Surgical treatment of varicose veins on the contralateral extremity may be considered medically necessary only if that leg is also symptomatic.
Code 36470
- Sclerotherapy for one (1) vein on the same leg.
- Report this code only once per leg per session.
- Surgical treatment of varicose veins on the contralateral extremity may be considered medically necessary only if that leg is also symptomatic.
Code 36471
- Sclerotherapy for multiple veins on the same leg.
- Report this code only once per leg per session.
- Surgical treatment of varicose veins on the contralateral extremity may be considered medically necessary only if that leg is also symptomatic.
Procedure Codes
| 36465 | 36466 | 36470 | 36471 | 76942 | J3490 |
