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Surgical Treatment of Varicose Veins

Section: Surgery
Effective Date: March 01, 2020
Revised Date: January 22, 2020
Last Reviewed: January 22, 2020

Description

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.

Criteria

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:

  • The individual has ANY ONE of the following: 
    • Documented limitations of activities of daily living caused by persistent severe lower extremity symptoms attributable to the varicose vein(s) (including but not limited to ache, pain, tightness, skin irritation, heaviness, muscle cramps) that fail to respond to conventional treatment; or
    • Ulceration secondary to venous stasis; or
    • Hemorrhage or recurrent bleeding episodes from ruptured superficial varicosity; or
    • Recurrent superficial thrombophlebitis that fails to respond to conservative treatment; and
  • Clinical documentation must indicate at least three (3) months of failed conservative treatment and include ALL of the following:
    • Gradient compression garments providing a minimum of 20-30 mmHg pressure; and
    • Leg elevation; and
    • Walking/exercising regularly as often as possible; and
    • Clinical, etiology, anatomy, pathophysiology (CEAP) class C2 or greater; and

(Conservative treatment is not required in cases of CEAP levels five (5) and six (6))

  • Venous imaging studies documenting any incompetence/reflux in the superficial system veins (great saphenous veins, small saphenous veins and saphenous tributaries); and

Imaging Requirements: 

  • Doppler ultrasound or duplex study performed no more than 12 months prior to the procedure and include documentation of ALL of the following:
  • Visibility; and
  • Compressibility; and
  • Augmentation; and
  • Absence of acute deep venous thrombosis (DVT); and
  • Reflux where at least ONE of the following is present:
    •  At least 500 msec for saphenous, tibial, deep femoral and perforating veins; or
    • At least one (1) second for femoral and popliteal veins; and
  • Vein size criterion is: at least 5mm; and

Treatment Sessions:

  • Initial treatment: unilateral or bilateral.
  • Additional treatments after the initial session:
    • Must meet ALL coverage criteria as outlined above; and
    • No need to document new conservative treatments if they were previously established for vein procedure and documented;
  • Endovenous ablation or cyanoacrylate adhesive:
    • One treatment session each of the greater saphenous vein; one session for the left greater saphenous vein or one session for the right greater saphenous vein, totaling two (2) sessions.
    • One treatment session each of the small saphenous vein; one session for the left small saphenous vein or one session for the right small saphenous vein, totaling two (2) sessions.

Follow-up Imaging:

  • Follow-up venous studies may be considered medically necessary within 48-72 hours after endovenous ablation for the purpose of excluding a DVT.  ALL other follow-up venous studies or ultrasounds performed within six (6) months following the most recent ipsilateral treatment, in the absence of complications, are considered not medically necessary.
  • Follow-up venous studies or ultrasound performed six (6) months or longer following the most recent ipsilateral treatment may be considered medically necessary when ALL of the other general criteria above are met.

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:

  • Ligation/stripping and Ambulatory Phlebectomy (i.e., stab, hook, transilluminated powered) 
  • Endovenous Radiofrequency, Endovenous Laser Ablation/Treatment (EVLA/EVLT) and Endomechanical Ablation 
  • Echosclerotherapy 
  • Sclerotherapy (Liquid or Microfoam) 
  • Subfascial Endoscopic Perforator Surgery (SEPS) 
  • Cyanoacrylate

If general medical necessity criteria are not met, see specific procedures and treatment of specific veins below for appropriate denial criteria.

Procedure Codes

36470 36471 36475 36476 36478 36479 36482
36483 37500 37700 37718 37722 37735 37765
37766 37780 37785 37799 76942 76998 S2202

 

Criteria for Specific Procedures

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:

  • Great saphenous vein symptoms including but not limited to leg/ankle swelling, skin changes, or a venous stasis ulcer; or
  • Small saphenous vein symptoms including but not limited to lateral ankle and foot swelling, or a venous stasis ulcer; and
  • ALL of the general medically necessary criteria above are met; and
  • One (1) treatment session each of the great saphenous veins; one (1) session for the left great saphenous or one (1) session for the right great saphenous, totaling two (2) sessions; and
  • One (1) treatment session each of the small saphenous veins; one (1) session for the left small saphenous or one (1) session for the right small saphenous, totaling two (2) sessions.

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).

Procedure Codes

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:

  • Perforator vein size at least 3.5 mm in diameter; and
  • CEAP Class C5-C6.

Echosclerotherapy performed for any other indication is considered not medically necessary.

Procedure Codes

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:

  • Great saphenous vein symptoms including but not limited to leg/ankle swelling, skin changes, or a venous stasis ulcer; or
  • Small saphenous vein symptoms including but not limited to lateral ankle and foot swelling, or a venous stasis ulcer; and
  • ALL of the general medically necessary criteria above are met; and
  • One (1) treatment session each of the great saphenous veins; one (1) session for the left great saphenous vein or one (1) session for the right great saphenous vein, totaling two (2) sessions; and
  • One (1) treatment session each of the small saphenous veins; one (1) session for the left small saphenous vein or one (1) session for the right small saphenous vein, totaling two (2) sessions

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.

Procedure Codes

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:

  • Related incompetent superficial veins proximal to the incompetent vein to be treated either have been or are being treated concurrently; and
  • ALL of the general medical necessary criteria above 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.

Procedure Codes

37700 37718 37722 37735 37765 37766 37780
37785

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

Treatments of Specific Vein Types

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:

  • Incompetence of the accessory saphenous vein is isolated, or the great saphenous vein or small saphenous vein has been previously eliminated (at least three (3) months); and
  • There is demonstrated accessory saphenous reflux; and
  • Ultrasound demonstrates vein size at least five (5) mm in diameter; and
  • There is documentation of ANY ONE of the following:
    • Ulceration secondary to venous stasis; or
    • Recurrent superficial thrombophlebitis that fails to respond to conservative therapy; or
    • Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity; or
    • Symptomatic varicose veins (as defined above) AND supporting clinical documentation.

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.

Procedure Codes

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.

Procedure Codes

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;

  • There is demonstrated perforator reflux; and
  • The superficial saphenous veins (great saphenous vein, small saphenous vein, or accessory saphenous veins and symptomatic varicose tributaries) have been previously eliminated; and
  • Ulcers have not resolved following combined superficial vein treatment and compression therapy for at least three (3) months; and
  • The venous insufficiency is not secondary to a DVT.

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.

Procedure Codes

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).

Procedure Codes

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.

Procedure Codes

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.

Procedure Codes

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.

Procedure Codes

0524T 36473 36474

Spider Veins, Treatment

Treatment for reticular veins and/or superficial telangiectasia’s, including laser, is considered cosmetic, and therefore, non-covered.

Procedure Codes

17106 17107 17108 36468 37799

CEAP Classification System

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 

Diagnosis Codes

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

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