When conservative treatments fail to provide relief from symptomatic varicosities, the following surgical options are eligible for reimbursement when reported for symptomatic varicose veins (454.0-454.8). Surgical treatment of varicose veins on the contralateral extremity is eligible only if that leg is also symptomatic.

When reported for non-symptomatic varicose veins (454.9) these surgical options are considered cosmetic. Participating, preferred, or network providers can bill the member for these denied services.

NOTE:

Conservative treatment includes the use of elastic stockings to provide support during daily activities, regular walking and elevating the feet as often as possible.

Symptomatic varicose veins include swelling, generalized leg aching, heaviness and restlessness, itching around the veins, leg cramps, leg muscles that tire easily and sores on the skin near the ankle. Veins may also appear stretched, bulging, and discolored.

Ligation and Stripping (procedure codes 37700-37785)
Ligation and stripping procedures are beneficial in the treatment of symptomatic varicose veins and, as such, are covered surgical services.

NOTE:

Code 37785 includes the ligation, division and/or excision of one or more clusters and should only be reported once per extremity.

In some cases, limited sclerotherapy may be necessary during the routine surgical postoperative period to achieve a better and more complete surgical result. As such, sclerotherapy performed by the surgeon, his associate or, the assistant surgeon during the postoperative period following vein ligation and stripping procedures is part of the global surgical allowance. A participating, preferred, or network provider cannot bill the member separately for these services.

Echosclerotherapy (procedure code S2202)
Coverage for echosclerotherapy is indicated only for symptomatic varicose veins (454.0-454.8) that have failed conservative therapy. If reported for indications other than symptomatic varicose veins, it is considered not medically necessary. Effective January 26, 2009, a participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

Echosclerotherapy should be reported under code S2202 which includes the injection and the ultrasound. Separate payment will not be made for the ultrasound guidance. If billed separately, the ultrasound should be denied as not covered. A participating, preferred, or network provider cannot bill the member for the denied service.

Description
Symptomatic varicose veins not visible to the naked eye can be treated by injection guided by ultrasonography. The combined procedure is called echosclerotherapy.

During echosclerotherapy, duplex ultrasound is used to guide the injections and enhance the precision of the therapy. Echosclerotherapy is also called aimed sclerotherapy, duplex sclerotherapy, or sonographic sclerotherapy.

Treatment of Spider Veins
Treatment for reticular veins and/or superficial telangiectases, including laser, is primarily cosmetic in nature.

• The injection of sclerosing solution into telangiectases such as spider veins, hemangiomata and angiomata should be reported with codes 36468 and 36469).
• Laser destruction of reticular veins and/or telangiectasis (e.g., VascuLite) should be reported with code 37799 (Unlisted procedure, vascular surgery).

Procedure codes 17106-17108 should not be used to report the treatment of reticular veins and/or spider veins.

Participating, preferred, or network providers can bill the member for services denied as cosmetic.

See Medical Policy Bulletin S-28 for information regarding Cosmetic Surgery.

Visual Sclerotherapy (procedure codes 36470 and 36471)
This service is eligible for payment for those patients who meet all of the following criteria:

• The patient should be symptomatic (e.g., the varicosities are resulting in pain, burning, etc.).
• There is no sapheno-femoral insufficiency or disease/occlusion of the deep venous system.
• The veins are demonstrable (bulging) above the surface of the skin.
• The varicosities are at least 5 millimeters in size.
• Medical management (e.g., compression therapy) has failed.

This procedure should be reported under codes 36470 for one vein or 36471 for multiple veins on the same leg.  Code 36471 should be reported only once per leg.

When visual sclerotherapy is performed on both legs at the same surgical session, services will be processed in accordance with the bilateral multiple surgery guidelines on Medical Policy Bulletin S-100.

Visual sclerotherapy treatment for reasons other than those listed above is considered cosmetic, and therefore, not covered.

Description
The injection of sclerosing solution into varicose leg veins irritates the lining of the vein causing it to close. The blood flow is then diverted through healthier veins.

Endovenous Radiofrequency Obliteration of Incompetent Veins (procedure codes 36475, 36476)
Endovenous radiofrequency obliteration is a covered service. Procedure codes 36475 and 36476 include the imaging guidance. Separate payment will not be made for imaging guidance reported with procedure codes 36475 and/or 36476.

Description
Endovenous radiofrequency (e.g., the VNUS Closure procedure) is a minimally invasive treatment used as an alternative to saphenous vein ligation and stripping in patients with symptomatic venous insufficiency of the lower extremities (e.g., varicose veins). It involves the use of a catheter temporarily inserted into the patient’s saphenous vein. This procedure utilizes radiofrequency energy at the catheter tip to heat the vein to approximately 85 degrees, which results in contraction of the vein. As the catheter is slowly withdrawn from the vein, the heat causes the vein to collapse and occlude thus terminating the reflux that causes the patient’s symptoms.

The catheter insertion is part of the overall procedure and should not be billed separately. If billed separately (e.g., 36010, 36011), the catheter insertion should be denied as not covered. A participating, preferred, or network provider cannot bill the member for the denied service.

Laser Obliteration of Incompetent Veins (procedure codes 36478, 36479)
Laser obliteration with ultrasonic guidance is a covered service. Procedure codes 36478 and 36479 include imaging guidance. Separate payment will not be made for imaging guidance billed with procedure codes 36478 and/or 36479.

NOTE:

Procedure codes 17106-17108 should not be used to report laser destruction of varicose veins.

Description
Laser obliteration of incompetent veins is also a minimally invasive procedure that is performed in a fashion similar to endovenous radiofrequency obliteration. A bare tipped laser fiber is introduced into the saphenous vein under ultrasonic guidance. The laser is activated and slowly removed along the course of the saphenous vein.

Ambulatory Phlebectomy (e.g., Stab Phlebectomy - procedure codes 37765, 37766, 37799)
Ambulatory phlebectomy is an eligible service.

Description
Ambulatory phlebectomy is a minimally invasive procedure performed as an alternative to ligation and stripping of veins that are too large for successful sclerotherapy. Prior to the procedure, the veins are located using a Doppler ultrasound. After the vein is marked, it is removed through pinhole incisions made along the length of the vein.

When performing fewer than ten (10) incisions, report 37799.

Transilluminated Powered Phlebectomy (procedure code 37785)
Transilluminated powered phlebectomy (TPPS) is considered an eligible alternative treatment of varicose veins.

Description
Transilluminated powered phlebectomy (e.g., TriVex System) is a minimally invasive procedure in which an endoscopic illuminator is inserted into the vein to allow visualization of the varicose vein clusters. The veins are then ablated using a vein resector. During destruction of the veins, the debris is removed from the wound using suction.

The following services are not eligible for reimbursement:

Non-Invasive Laser Treatment (procedure code 37799)
Date Last Reviewed - 07/2007
Non-invasive laser treatment of veins is not covered. This method of treatment, e.g., Vasculite Nd Yag, intense pulsed light (IPL), performed for small superficial, reticular, and telangiectatic veins is cosmetic. A participating, preferred, or network provider can bill the member for this denied service.

In addition, this method of treatment for larger veins is considered investigational and, therefore, is not covered. Scientific evidence does not demonstrate the effectiveness of this treatment. A participating, preferred, or network provider can bill the member for the denied service.

Subfascial Endoscopic Perforator Surgery (SEPS - procedure code 37500)
Date Last Reviewed - 12/2006
Subfascial endoscopic perforator surgery (SEPS) is considered investigational. There is inadequate evidence to permit scientific conclusions about the efficacy of SEPS, either in terms of promoting healing of existing venous ulcers, or preventing their recurrence in comparison to medical therapy or to surgical treatment of the superficial venous system alone. Participating, preferred, and network providers can bill the member for the denied service.

Description
Subfascial endoscopic perforator surgery (SEPS) is a minimally invasive procedure designed to interrupt incompetent perforator veins. The perforator veins are those veins that connect the deep venous system (i.e., the femoral and popliteal veins) with the superficial venous system (i.e., the greater and lesser saphenous veins).

Description

Varicose veins, which usually occur in the lower extremities, are dilated superficial veins whose valves have become incompetent, permitting reversed blood flow when the extremities are in the dependent position. The vascular dilatation results from increased pressure within the veins, as often occurs if the individual stands for long periods of time. Genetics, pregnancy and obesity contribute to the development of varicose veins.

Symptoms, which are not necessarily related to the size of the varicosity, include swelling, generalized leg aching, heaviness and restlessness, itching around the veins, leg cramps, leg muscles that tire easily and sores on the skin near the ankle. The veins may also appear stretched, bulging and discolored.

Varicose veins should be treated conservatively with the use of elastic stockings to provide support during daily activities. Since prolonged standing exacerbates the condition, regular walking and elevating the feet as often as possible should be encouraged.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

PRN References

10/1993, Sclerotherapy of Varicose Veins, coverage for
05/1994, Sclerotherapy, postoperative, reimbursement for
08/1998, Echosclerotherapy
12/2000, Endovenous radiofrequency obliteration of the greater saphenous vein considered investigational
12/2001, How to report laser destruction of varicosities
12/2002, Endovenous radiofrequency obliteration of the greater saphenous vein eligible for reimbursement
06/2003, Blue Shield pays for specific treatments of symptomatic varicose veins, treatment of spider veins not covered
12/2003, Non-invasive laser treatment of vein not covered
04/2004, How to report radiofrequency obliteration of the greater saphenous vein
04/2005, Subfascial endoscopic perforator surgery (SEPS) considered investigational
04/2006, How to report stab phlebectomies
08/2006, How to report injection of sclerosing agent into veins
02/2009,  Echosclerotherapy eligible for symptomatic varicose veins

Closure of the Greater Saphenous Vein with Endoluminal Radiofrequency Thermal Heating of the Vein Wall in Combination with Ambulatory Phlebectomy: Preliminary 6-Month Follow-up, Dermatologic Surgery, Volume 26, Issue 5, May 2000

Treatment of Primary Venous Insufficiency by Endovenous Saphenous Vein Obliteration, Vascular Surgery, Volume 34, No. 3, May/June 2000

Endovenous Techniques for Elimination of Saphenous Reflux: A Valuable Treatment Modality, Dermatologic Surgery, Volume 27, No. 10, October 2001

Closure of the Greater Saphenous Vein with Endoluminal Radiofrequency Thermal Heating of the Vein Wall in Combination with Ambulatory Phlebectomy: 50 Patients with More than 6-Month Follow-up, Dermatologic Surgery, Volume 28, No. 1, January 2002

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Endovenous Laser Treatment of the Incompetent Greater Saphenous Vein, Journal of Vascular Interventional Radiology, Volume 12, No. 10, October 2001

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Powered Phlebectomy (TriVex) in Treatment of Varicose Veins, Annals of Vascular Surgery, 2002

MPRM 7.01.90

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Laser Treatment of Leg Veins, Seminars in Cutaneous Medicine and Surgery, Volume 24; 2005

Optimal Pulse Durations for the Treatment of Leg Telangiectasias with a Neodymium YAG laser, Lasers in Surgery and Medicine, Volume 38, February 2006

A Side-by-Side Prospective Study of Intense Pulsed Light and Nd: YAG Laser Treatment for Vascular Lesions, Annals of Plastic Surgery, Volume 56, Number 2, February 2006

The 800-nm diode laser in the treatment of leg veins: Assessment at 6 months, Journal of the American Academy of Dermatology, Volume 54, Number 2, February 2006

Bountouroglou DG, Azzam M, Kakkos SK, Pathmarajah M, Young P, Geroulakos G. Ultrasound-guided Foam Sclerotherapy Combined with Sapheno-femoral Ligation Compared to Surgical Treatment of Varicose Veins: Early Results of a Randomized Controlled Trial. Eur J Vasc Endovasc Surg. 2006;31:93-100.

Smith PC. Chronic Venous Disease Treated by Ultrasound Guided Foam. Sclerotherapy. 2006;32:577-583.

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