A variety of treatment modalities are available to treat varicose veins/venous insufficiency, including surgical approaches, thermal ablation, and sclerotherapy. The application of each of these treatment options is influenced by the severity of the symptoms, type of vein, source of venous reflux, and the use of other (prioror concurrent) treatments.
General medical necessity criteria for coverage of symptomatic varicose veins:
Treatment for symptomatic varicose veins may be considered medically necessary when ALL of the following criteria are met for all varicose vein treatments:
(Conservative treatment is not required in cases of CEAP levels five (5) and six (6))
Imaging Requirements:
Treatment Sessions:
Follow-up Imaging:
Accepted Procedures:
When conservative treatments fail to provide relief from symptomatic varicosities and ALL the above general criteria requirements are met, the following options may be considered medically necessary when reported for symptomatic varicose veins. However, in addition to the general medically necessary criteria above, specific requirements for each procedure must also be met:
If general medical necessity criteria are not met, see specific procedures and treatment of specific veins below for appropriate denial criteria.
36470 | 36471 | 36475 | 36476 | 36478 | 36479 | 36482 |
36483 | 37500 | 37700 | 37718 | 37722 | 37735 | 37765 |
37766 | 37780 | 37785 | 37799 | 76942 | 76998 | S2202 |
Cyanoacrylate Adhesive (Great Saphenous, Small Saphenous and Accessory Saphenous Veins)
Treatment of the great saphenous or small saphenous veins with cyanoacrylate adhesive may be considered medically necessary for symptomatic varicose veins/venous insufficiency when ALL of the following criteria are met:
Treatment of the great saphenous veins and small saphenous veins with cyanoacrylate adhesive not meeting the above criteria is considered cosmetic and therefore non-covered.
For accessory saphenous veins criteria, (see Accessory Saphenous Veins below).
36482 | 36483 |
Echosclerotherapy
Echosclerotherapy is a technique used for perforator veins. Duplex ultrasound guidance is used to inject a sclerosing agent into varicose veins.
Echosclerotherapy may be considered medically necessary when BOTH of the following criteria have been met:
Echosclerotherapy performed for any other indication is considered not medically necessary.
S2202 |
Endovenous Radiofrequency, Endovenous Laser Ablation/Treatment (EVLA/EVLT) and Endomechanical Ablation
Treatment of the great saphenous veins and small saphenous veins may be considered medically necessary when ALL of the following criteria are met:
Endovenous ablation procedures for the treatment of the great saphenous and the small saphenous veins for all other conditions are considered cosmetic and therefore non-covered.
36475 | 36476 | 36478 | 36479 | 37799 |
Ligation and Stripping and Phlebectomy (i.e., Stab, Hook, Transilluminated Powered)
Treatment of the great saphenous veins, small saphenous veins and/or saphenous tributaries may be considered medically necessary when the following criteria are met:
Ligation and stripping, ambulatory phlebectomy (i.e., stab, hook, transilluminated powered) for conditions other than symptomatic veins, are considered cosmetic, and therefore, non-covered. This includes the diagnosis of non-symptomatic varicose veins.
37700 | 37718 | 37722 | 37735 | 37765 | 37766 | 37780 |
37785 |
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:
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;
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.
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.
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
Code 36471
36465 | 36466 | 36470 | 36471 | 76942 | J3490 |
Accessory Saphenous Veins
Treatment of accessory saphenous veins by ligation and stripping, endovenous radiofrequency, laser ablation or cyanoacrylate adhesive may be considered medically necessary for symptomatic varicose veins/venous insufficiency when ALL of the following criteria have been met:
Non-covered
Treatment of accessory saphenous veins by ligation and stripping, endovenous radiofrequency, laser ablation, or cyanoacrylate that do not meet the coverage criteria described above is considered cosmetic and therefore non-covered.
36475 | 36476 | 36478 | 36479 | 36482 | 36483 | 37700 |
37718 | 37722 | 37765 | 37766 | 37780 | 37785 | 37799 |
Greater Saphenous Vein Treatments (see Criteria for Specific Procedures above)
Ligation and stripping and phlebectomy (i.e., stab, hook, transilluminated powered), endovenous radiofrequency, endovenous laser ablation/treatment (EVLA/EVLT), endomechanical ablation, or cyanoacrylate adhesive.
36475 | 36476 | 36478 | 36479 | 36482 | 36483 | 37700 |
37718 | 37722 | 37765 | 37766 | 37780 | 37785 | 37799 |
Perforator Veins: Subfascial endoscopic perforator surgery (SEPS) or endovenous radiofrequency or laser ablation may be considered medically necessary as a treatment of leg ulcers associated with chronic venous insufficiency when the following criteria have been met;
Ligation or ablation of incompetent perforator veins performed concurrently with superficial venous surgery is not considered not medically necessary.
SEPS, endovenous radiofrequency or laser ablation performed on perforator veins that do not meet the criteria above will be considered cosmetic and therefore non-covered.
36475 | 36476 | 36478 | 36479 | 37500 | 37799 |
Saphenous Tributaries (see Criteria for Specific Procedures above)
Ligation and stripping and phlebectomy (i.e., stab, hook, transilluminated powered) or sclerotherapy (liquid or microfoam).
36465 | 36466 | 36470 | 36471 | 37700 | 37718 | 37722 |
37735 | 37765 | 37766 | 37780 | 37785 | 37799 | 76942 |
J3490 |
Small Saphenous Vein Treatments (see Criteria for Specific Procedures above)
Ligation and stripping and phlebectomy (i.e., stab, hook, transilluminated powered), endovenous radiofrequency, endovenous laser ablation/treatment (EVLA/EVLT), endomechanical ablation or sclerotherapy (liquid or microfoam) or cyanoacrylate adhesive.
36465 | 36466 | 36470 | 36471 | 36475 | 36476 | 36478 |
36479 | 36482 | 36483 | 37700 | 37718 | 37722 | 37765 |
37766 | 37780 | 37785 | 37799 | 76942 | J3490 |
Non-Covered Services
Endovenous Cryoablation
Endovenous cryoablation of any vein is considered experimental/investigational and therefore non- covered. Scientific evidence does not demonstrate the effectiveness of this treatment.
Laser Treatment, Non-Invasive
Non-invasive laser treatment, e.g., Vasculite Nd Yag, intense pulsed light (IPL), performed on small superficial, reticular, and telangiectatic veins is considered cosmetic and therefore non-covered.
This method of treatment for larger veins is considered experimental/investigational and therefore non-covered. Scientific evidence does not demonstrate the effectiveness of this treatment.
37799 |
Mechanochemical Ablation (MCA)/(MOCA)
Mechanochemical ablation of any method, of any vein (i.e., ClariVein® system) is considered experimental/investigational and therefore non-covered. Scientific evidence does not demonstrate the safety and efficacy of this treatment.
0524T | 36473 | 36474 |
Spider Veins, Treatment
Treatment for reticular veins and/or superficial telangiectasia’s, including laser, is considered cosmetic, and therefore, non-covered.
17106 | 17107 | 17108 | 36468 | 37799 |
Class | Description |
C0 | No visible or palpable signs of venous disease |
C1 | Telangiectasies or reticular veins |
C2 | Varicose veins |
C3 | Edema |
C4a | Pigmentation and eczema |
C4b | Lipodermatosclerosis and atrophie blanche |
C5 | Healed venous ulcer |
C6 | Active venous ulcer |
Covered Diagnosis Codes for Procedure Codes 36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37765, 37766, 37780 and 37785
I80.00 | I80.01 | I80.02 | I80.03 | I83.10 | I83.11 | I83.12 |
I83.001 | I83.002 | I83.003 | I83.004 | I83.005 | I83.008 | I83.009 |
I83.011 | I83.012 | I83.013 | I83.014 | I83.015 | I83.018 | I83.019 |
I83.021 | I83.022 | I83.023 | I83.024 | I83.025 | I83.028 | I83.029 |
I83.201 | I83.202 | I83.203 | I83.204 | I83.205 | I83.208 | I83.209 |
I83.211 | I83.212 | I83.213 | I83.214 | I83.215 | I83.218 | I83.219 |
I83.221 | I83.222 | I83.223 | I83.224 | I83.225 | I83.228 | I83.229 |
I83.811 | I83.812 | I83.813 | I83.819 | I83.891 | I83.892 | I83.893 |
I83.899 | I87.2 | I87.9 |