Saphenous Veins
Great or Small Saphenous Veins
Treatment of the great or small saphenous veins by surgery (ligation and stripping), endovenous thermal ablation (radiofrequency or laser), microfoam sclerotherapy or cyanoacrylate adhesive may be considered medically necessary for symptomatic varicose veins/venous insufficiency when the following criteria have been met:
There is demonstrated saphenous reflux and CEAP [Clinical, Etiology, Anatomy, Pathophysiology] class C2 or greater; AND
There is documentation of 1 or more of the following indications:
Ulceration secondary to venous stasis; OR
Recurrent superficial thrombophlebitis; OR
Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity; OR
Persistent pain, swelling, itching, burning, or other symptoms are associated with saphenous reflux, AND the symptoms significantly interfere with activities of daily living, AND conservative management including compression therapy for at least 3 months has not improved the symptoms.
Treatment of great or small saphenous veins by surgery, endovenous radiofrequency or laser ablation, microfoam sclerotherapy or cyanoacrylate adhesive that does not meet the criteria described above is considered cosmetic and is considered investigational.
Accessory Saphenous Veins
Treatment of accessory saphenous veins by surgery (ligation and stripping), endovenous radiofrequency or laser ablation, microfoam sclerotherapy or cyanoacrylate adhesive may be considered medically necessary for symptomatic varicose veins/venous insufficiency when the following criteria have been met:
Incompetence of the accessory saphenous vein is isolated, AND
There is demonstrated accessory saphenous reflux; AND
There is documentation of 1 or more of the following indications:
Ulceration secondary to venous stasis; OR
Recurrent superficial thrombophlebitis; OR
Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity; OR
Persistent pain, swelling, itching, burning, or other symptoms are associated with saphenous reflux, AND the symptoms significantly interfere with activities of daily living, AND conservative management including compression therapy for at least 3 months has not improved the symptoms.
Concurrent treatment of the accessory saphenous veins along with the great or small saphenous veins may be considered medically necessary when criteria is met for each vein and there is documentation of anatomy showing that the accessory saphenous vein discharged directly into the common femoral vein.
Treatment of accessory saphenous veins by surgery, endovenous radiofrequency or laser ablation, or microfoam sclerotherapy or cyanoacrylate adhesive that does not meet the criteria described above is considered cosmetic and investigational.
Symptomatic Varicose Tributaries
The following treatments are considered medically necessary as a component of the treatment of symptomatic varicose tributaries when performed either at the same time or following prior treatment (surgical, radiofrequency, or laser) of the saphenous veins (none of these techniques has been shown to be superior to another):
Stab avulsion
Hook phlebectomy
Sclerotherapy
Transilluminated powered phlebectomy.
Treatment of symptomatic varicose tributaries, when performed either at the same time or following prior treatment of saphenous veins using any other techniques than those noted above, is considered investigational.
Perforator Veins
Surgical ligation (including subfascial endoscopic perforator surgery) or endovenous radiofrequency or laser ablation of incompetent perforator veins may be considered medically necessary as a treatment of leg ulcers associated with chronic venous insufficiency when the following conditions have been met:
There is demonstrated perforator reflux; AND
The superficial saphenous veins (great, small, or accessory saphenous and symptomatic varicose tributaries) have been previously eliminated; AND
Ulcers have not resolved following combined superficial vein treatment and compression therapy for at least 3 months; AND
The venous insufficiency is not secondary to deep venous thromboembolism.
Ligation or ablation of incompetent perforator veins performed concurrently with superficial venous surgery is investigational.
Telangiectasia
Treatment of telangiectasia such as spider veins, angiomata, and hemangiomata is considered cosmetic and investigational.
Other Veins
Techniques for conditions not specifically listed above are investigational, including, but not limited to:
Sclerotherapy techniques, other than microfoam sclerotherapy, of great, small, or accessory saphenous veins
Sclerotherapy of perforator veins
Sclerotherapy of isolated tributary veins without prior or concurrent treatment of saphenous veins
Stab avulsion, hook phlebectomy, or transilluminated powered phlebectomy of perforator, great or small saphenous, or accessory saphenous veins
Endovenous radiofrequency or laser ablation of tributary veins
Mechanochemical ablation of any vein
Endovenous cryoablation of any vein.
