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 dilation 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.

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.

Surgical treatment for symptomatic varicose veins is eligible for reimbursement when the patient presents with evidence of at least one of the following:

• Severe, persistent leg aching, burning, itching, cramping and/or swelling interfering with activities of daily living that fails to respond to conservative treatment; or,
• Ulceration secondary to venous stasis that fails to respond to conservative treatment; or,
• Hemorrhage or recurrent bleeding episodes from  ruptured superficial varicosity; or;
• Recurrent superficial thrombophlebitis that fails to respond to conservative treatment; or,
• Varicosities at least 5 mm in size for those patients being treated with sclerotherapy.

In addition to the medical necessity guidelines outlined for symptomatic varicose veins, subfascial endoscopic perforator surgery (SEPS) is covered when there is documented Doppler evaluation and/or Duplex ultrasonography of the incompetent perforator vein, and it is located on the medial aspect of the calf being treated.

Failed conservative treatment must include at least 3 months of conservative treatment that includes all of the following:

• Compression hose providing at least 30 mm Hg pressure;
• Leg elevation above heart level as often as possible; and,
• Walking/exercising regularly as often as possible.

When conservative treatments fail to provide relief from symptomatic varicosities, the following surgical options are eligible for reimbursement when reported for symptomatic varicose veins:

• Visual Sclerotherapy (36470 and 36471)
• Echosclerotherapy (S2202)
• Ligation of long and/or short saphenous veins, perforator veins, or venous clusters (37700-37761, 37780-37785)
• Ambulatory Phlebectomy (e.g., Stab Phlebectomy)(37765, 37766, 37799)
• Endovenous Radiofrequency Obliteration of Incompetent Veins (codes 36475, 36476)
• Laser Obliteration of Incompetent Veins (36478, 36479)
• Transilluminated Powered Phlebectomy (37799)
• Subfascial Endoscopic Perforator Surgery (SEPS - procedure code 37500)

When reported for conditions other than symptomatic varicose veins, these surgical options are considered cosmetic. This includes the diagnosis of non-symptomatic varicose veins. Participating, preferred, or network providers can bill the member for these denied services.

When reporting these services, the following guidelines apply:

• 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.
  
  
• Sclerotherapy 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.
  
  

• Echosclerotherapy should be reported under code S2202 which includes the ultrasound (76937, 76942, or 76998).
  

• Ambulatory phlebectomy services, procedures codes 37765 and 37766, are reported based on the number of incisions performed on each extremity. When fewer than 10 incisions are required, report code 37799.
  
  
• Procedure code 37785 includes the ligation, division, and/or excision of one or more varicose vein clusters and should only be reported once per extremity. Report code 37785 with modifier RT, LT, or 50 as appropriate.
  
  
• Ligation of perforator veins, code 37761, includes ultrasound guidance.  
  
  
• Endovenous radiofrequency obliteration of veins (VNUS) and laser obliteration of incompetent veins (EVLT) include imaging guidance. 
  
  
• Endovenous radiofrequency obliteration of veins (VNUS) and laser obliteration of incompetent veins also include catheter insertion as part of the overall procedure.  
  
  
• Surgical treatment of varicose veins on the contralateral extremity is eligible only if that leg is also symptomatic.
  
  
• Reimbursement for codes 36470 and 36471 includes the cost of the sclerosing agent; therefore, when code J3490 is reported in addition to code 36470 or 36471, no additional allowance will be made. Modifier 59 may be reported with code J3490 to identify it as a significant, separately identifiable service from the sclerotherapy. When the 59 modifier is reported, the patient's records must clearly document that an injection was provided independently. Also when you report code J3490, please include the name of the drug in the narrative section of the electronic or paper claim.

The following services are not eligible for reimbursement:

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.

Non-Invasive Laser Treatment (procedure code 37799)

Date Last Reviewed - 09/2009

Non-invasive laser treatment of veins is non-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 non-covered service.

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

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.

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
08/2009, Subfascial endoscopic perforator surgery (SEPS) covered for certain indications
12/2010, Echosclerotherapy fee includes ultrasound guidance
12/2010, Subfascial endoscopic perforator surgery eligible for treating symptomatic varicose veins
12/2010, Sclerotherapy includes sclerosing agent
12/2010, Clinical criteria for surgical treatment of varicose veins explained

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

Controlled Radiofrequency Endovenous Occlusion Using a Unique Radiofrequency Catheter Under Duplex Guidance to Eliminate Saphenous Varicose Vein Reflux: A 2-Year Follow-up, Dermatologic Surgery, Volume 28, No. 1, January 2002

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

Endovenous Laser: A New Minimally Invasive Method of Treatment for Varicose Veins – Preliminary Observations Using an 810 nm Diode Laser, Dermatologic Surgery, Volume 27, 2001

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

MPRM 7.01.90

Barrett JM, Allen B, Ockelford A, Goldman MP. Microfoam Ultrasound-guided Sclerotherapy of Varicose Veins in 100 Legs. Dermatologic Surg. 2004;30:6-12.

Laser Treatment of Vascular Lesions, Dermatologic Clinics, Volume 23; 2005

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.

Bergan J, Pascarella L, Mekenas L. Venous Disorders: Treatment With Sclerosant Foam. J Cardiovascular Surg. 2006;47:9-18.

Uncu H. Subfascial Endoscopic Perforator Vein Surgery Using Balloon Dissector and Saphenous Vein Surgery for Chronic Venous Insufficiency. Phlebology. 2007:22(3):131-6.

Casian D, Gutu E, Moroz S. Initial Experience of Subfascial Endoscopic Perforator Vein Surgery n Patients with Severe Chronic Venous Insufficiency. Chirurgia (Bucur). 2007 Jul-Aug;102(4):415-9.

Nelzen O, Fransson I. True Long-Term Healing and Recurrence of Venous Leg Ulcers Following SEPS Combined with Superficial Venous Surgery: A Prospective Study. Eur J Vasc Endovasc Surg. 2007 Nov;34(5):605-12.

Blasco SB, Hernandez GM, Sabench PF, et al. Subfascial Endoscopic Perforator Surgery (SEPS) Modified Technique: Subaponeurotic Approach Without Balloon. Minim Invasive Ther Allied Technol. 2008;17(4):246-50.

Hirsch SA, Dillavou E. Options in the management of varicose veins, 2008. J Cardiovasc Surg. 2008;49(1):19-26.

Jones RH, Carek PJ. Management of varicose veins. Am Fam Physician. 2008;78(11):1289-94.

Galeckas KJ. Update on lasers and light devices for the treatment of vascular lesions. Semin Cutan Med Surg. 2008;27(4):276-84.

Ross EV, Meehan KJ, Gilbert S, Domankevitz Y. Optimal pulse durations for the treatment of leg telangiectasias with an alexandrite laser. Lasers Surg Med. 2009;41(2):104-9.