Coverage Policies

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 01/01/2004 Title: Varicose Vein Treatment
Revision Date: 02/01/2020 Document: BI093:00
CPT Code(s): 36465, 36466, 36470, 36471, 36473-36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799, 0524T
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

  1. Varicose vein surgery is covered when it is medically necessary.
  2. Pre-authorization is required.
  3. There are a number of treatment modalities for varicose veins, some of which are covered and some of which are not.

Medical Statement

1)    All Varicose veins treatment procedures require prior authorization. QualChoice Health Plan covers varicose vein ligation, excision, stripping, ablation and sclerotherapy for Intractable ulceration caused by venous stasis OR after there has been an unsuccessful trial of conservative management such as exercise, periodic leg elevation, weight loss, prescribed compressive therapy, and avoidance of prolonged immobility where appropriate, has failed for at least three (3) months AND when the saphenous varicosities result in any of the following:

a)    More than one episode of minor hemorrhage from a ruptured superficial varicosity; OR

b)    A single significant hemorrhage from a ruptured superficial varicosity, especially if transfusion of blood is required; OR

c)    Recurrent superficial thrombophlebitis; OR

d)    Severe and persistent pain and swelling interfering with activities of daily living and requiring chronic analgesic medication for at least three (3) months.

2)    Subfascial endoscopic perforator vein surgery (SEPS) is covered only for the treatment of members with advanced chronic venous insufficiency secondary to primary valvular incompetence of superficial and perforating veins, with or without deep venous incompetence, when conservative management has failed.

3)    Prior approval of surgical interventions is required.

4)    Sclerotherapy for single vein treatment is considered medically necessary for up to a maximum of two (2) units of service (one (1), if billed with modifier 50) per limb per calendar year

5)    Sclerotherapy for multiple vein treatments is is considered medically necessary for a maximum of one (1) unit of service for per limb, per calendar year.

6)    Any additional single or multiple vein sclerotherapy procedures (beyond the maximum within a calendar year) require a new prior authorization and a diagnostic study that is performed and interpreted by an independent radiologist.

7)    Radiofrequency and laser endovenous ablation of the saphenous vein are covered as alternatives to varicose vein ligation and stripping for patients who meet the medical necessity criteria. Significant advantages of these procedures in comparison to ligation and stripping of the saphenous vein have not been demonstrated. These procedures must be done at a contracted facility.

8)    The TriVex system (transilluminated powered phlebectomy) is covered as an alternative method for ambulatory phlebectomy. This is usually done on an outpatient basis. Significant advantages of the TriVex system over standard ambulatory phlebectomy have not been proven. The TriVex system is covered, if performed at a contracted facility.

9)    Sclerotherapy alone is rarely if ever used as definitive therapy for significant varicosities. It may be used in conjunction with surgical treatment (phlebectomy or ablation) to treat tributary veins; in such cases it is typically used at the same time as, or within a short time of, surgical treatment. Its use for spider veins is considered cosmetic and is not covered. All sclerotherapy codes MUST be submitted with modifier RT, LT, or 50. 

10) When sclerotherapy is proposed for the treatment of significant varices, the proposed treatment plan requires medical director review for indications and appropriateness of the choice of treatment technique. In any case, no more than two (2) sessions of sclerotherapy per limb will be authorized within one (1) year.

11) Photo thermal sclerosis (also referred to as intense pulsed light source) using the PhotoDerm VL, is used to treat small veins. Because such small veins are cosmetic problems and do not cause significant pain, bleeding, ulceration, or other medical problems, photo thermal sclerosis is not covered.

Codes Used In This BI:

36468

Sgl or mult inj of sclerosing solutions, spider veins; limb or trunk

36465

Inj of non-compounded foam sclerosant; sgl incompetent vein

36466

Inj of non-compounded foam sclerosant; mult incompetent veins

36470

Injection of sclerosing solution; single vein

36471

Inj of sclerosing solution; mult veins, same leg

36473

Endovenous ablation therapy of incompetent vein, extrem, incl of all imaging guidance & monitoring, percut, mechanochem; 1st vein treated

36474

Endovenous ablation therapy of incompetent vein, extrem, incl of all imaging guidance & monitoring, percut, mechanochem; subseq vein(s) treated in a sgl extrem, ea through sep access sites

36475

Endovenous ablation therapy of incompetent vein, extrem, incl of all imaging guidance & monitoring, percutan, radiofrequency; 1st vein treated

36476

Endovenous ablation therapy of incompetent vein, extrem, incl of all imaging guidance & monitoring, percutan, radiofrequency; subseq vein(s) treated in a sgl extrem, ea through sep access sites

36478

Endovenous ablation therapy of incompetent vein, extrem, incl of all imaging guidance & monitoring, percut, laser; 1st vein treated

36479

Endovenous ablation therapy of incompetent vein, extrem, incl of all imaging guidance & monitoring, percut, laser; subseq vein(s) treated in a sgl extrem, ea through sep access sites

36482

Endovenous ablation therapy of incompetent vein w/chemical adhesive incl of all imaging guidance & monitoring

36483

Endovenous ablation therapy of subseq incompetent vein w/chemical adhesive incl of all imaging guidance & monitoring

37500

Vascular endoscopy, surgical, w/ligation of perforator veins, sub fascial (SEPS)

37700

Ligation & division of long saphenous vein at saphenofemoral junction, or distal interruptions

37718

Ligation, division, & stripping, short saphenous

37722

Ligation & division & complete stripping of long or short saphenous veins

37735

Ligation & division & cmplt stripping of long or short saphenous veins w/radical excsn of ulcer & skin graft and/or interrup of communicating veins of lower leg, w/excsn of deep fascia

37760

Ligation of perforator veins, subfascial, radical (Linton type), w/ or w/out skin graft, open

37761

Ligation of perforator veins, subfascia, open, one leg

37765

Stab phlebectomy of varicose veins, one extremity; 10-20 stab incisions

37766

Stab phlebectomy of varicose veins, one extremity; more than 20 incisions

37780

Ligation & division of short saphenous vein at saphenopopliteal junction (sep proc)

37785

Ligation, division, and/or excision of varicose veins cluster(s), one leg

37799

Unlisted procedure, vascular surgery

0524T

Endovenous catheter-directed CHEM ABLTJ INCMPTNT XTR VEIN (New code 1/1/2019)


Reference

1.     Dixon PM. Duplex ultrasound in the pre-operative assessment of varicose veins. Australas Radiol 1996 Nov;40(4):416-421

2.     Campbell WB, Halim AS, Aertssen A, et al. The place of duplex scanning for varicose veins and common venous problems. Ann R Coll Surg Engl 1996 Nov;78(6):490-493

3.     Rutherford RB. Vascular Surgery. 4th Ed. Philadelphia, PA: W.B. Saunders Co., 1995

4.     Barker LR, Burton JR, Zieve PD. Principles of Ambulatory Medicine. 4th Ed. Baltimore, MD: Williams and Wilkins, 1995

5.     Schwartz SI, Shires GT, Spencer FC. Principles of Surgery. 6th Ed. New York, NY: McGraw-Hill, Inc., 1994.

6.     Liew SCC, Huber D, Jeffs C. Day-only admission for varicose vein surgery. Aust N Z J Surg 1994; 64(10):688-691.

7.     Jamieson WG. State of the art of venous investigation. CJS 1993; 36(2): 119-128, 1993.

8.     Fronek A. Non-invasive examination of the venous system in the leg: Presclerotherapy evaluation. J Dermatol Surg Oncol 1992; 15(2):170-171.

9.     Houghton AD, Panayiotopoulos Y, Taylor PR. Practical management of primary varicose veins. Br J Clin Pract 1996 Mar;50(2):103-105

10. Bergan, JJ. The current management of varicose and telangiectatic veins. Surgery Annual 1993; 25 Pt 1:141-156.

11. Neglen P, Einarsson E, Eklof B. The functional long-term value of different types of treatment for saphenous vein incompetence. J Cardiovasc Surg 1993; 34(4):295-301.

12. Goldman MP. Sclerotherapy: Treatment of Varicose and Telangiectatic Leg Veins. 2nd Ed. St. Louis, MO: Mosby, Inc., 1995.

13. Goldman MP, Weiss RA, Bergan JJ. Diagnosis and treatment of varicose veins: A review. J Am Acad of Dermatol 1994:31 (3 Pt 1):393-413.

14. DeGroot WP. Treatment of varicose veins: Modern concepts and methods. J Dermatol Surg 1989:15(2):191-198.

15. Zimmet SE. Venous leg ulcers: modern evaluation and management. Dermatol Surg 1999 Mar; 25(3):236-41.

16.  Recommendations and medical references of ANAES. Indications for surgical treatment of primary varicosities of the legs. J Mal Vasc 1998 Oct, 23(4): 297-308.

17.  Dortu JA, Constancias-Dortu I. [Treatment of varicose veins of the lower limbs by ambulatory phlebectomy (Muller`s method): technique, indications and results]. Ann Chir 1997; 51(7): 761-72.

18. Guidelines of care for sclerotherapy treatment of varicose and telangiectatic leg veins. American Academy of Dermatology. J Am Acad Dermatol 1996 Mar; 34(3): 523-8.

19. ESC Medical Systems. Leg veins: eliminate unattractive leg veins with PhotoDerm VL. Needham, MA: ESC Medical Systems Ltd., 1996. ESC Medical Systems. Facial spider veins and vascular birthmarks: Eliminate unattractive cosmetic blemishes with PhotoDerm VL. Needham, MA: ESC Medical Systems Ltd., 1996.

20. Goldman MP, Eckhouse S. Photo thermal sclerosis of leg veins. Dermatol Surg 1996:22(4): 323-330.

21. Cochrane Evidence: Wearing stockings to provide compression for the treatment of varicose veins. Shingler S, Robertson L, Boghossian S, Stewart M. December 2013.

Addendum:

1.     Effective 01/01/2017: 2017 Coding Updates. Added new CPT codes 36473 and 36474 to BI. Also updated code description throughout BI to CPT codes 36476 and 36479, omitting the word “second” from “second and subsequent vein” to read “subsequent vein(s).”  

2.     Effective 05/01/2017: Treatment of Intractable ulceration caused by venous stasis and varicose veins does not require trial of conservative management.

3.     Effective 12/01/2017: Trial period for conservative management is at least three months before varicose vein ligation, excision, stripping, ablation or sclerotherapy procedures.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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