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Date Printed: October 20, 2017: 08:41 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-33000-31

Original Effective Date: 02/15/02

Reviewed: 06/22/17

Revised: 07/15/17

Subject: Treatments for Varicose Veins/Venous Insufficiency

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

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 (prior or concurrent) treatments.

Treatment of venous reflux/venous insufficiency is aimed at reducing abnormal pressure transmission from the deep to the superficial veins. Conservative medical treatment consists of elevation of the extremities, graded compression, and wound care when indicated. Conventional surgical treatment consists of identifying and correcting the site of reflux by ligation of the incompetent junction followed by stripping of the vein to redirect venous flow through veins with intact valves. While most venous reflux is secondary to incompetent valves at the saphenofemoral or saphenopopliteal junctions, reflux may also occur at incompetent valves in the perforator veins or in the deep venous system. Varicose veins with visible varicosities may be the only sign of venous reflux, although itching, heaviness, tension, and pain may also occur. Chronic venous insufficiency secondary to venous reflux can lead to thrombophlebitis, leg ulcerations, and hemorrhage. The CEAP classification considers the clinical, etiologic, anatomic, and pathologic (CEAP) characteristics of venous insufficiency, ranging from class 0 (no visible sign of disease) to class 6 (active ulceration).

POSITION STATEMENT:

Great or Small Saphenous Veins

Treatment of the great or small saphenous veins by surgery (ligation and stripping), endovenous radiofrequency, laser ablation, or microfoam sclerotherapy meets the definition of medical necessity for symptomatic varicose veins/venous insufficiency when the following criteria have been met:

  1. Ulceration secondary to venous stasis; OR
  2. Recurrent superficial thrombophlebitis; OR
  3. Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity; OR
  4. 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, laser ablation, or microfoam sclerotherapy that do not meet the criteria described above is considered cosmetic and does not meet the definition of medical necessity.

Accessory Saphenous Veins

Treatment of accessory saphenous veins by surgery (ligation and stripping), endovenous radiofrequency, laser ablation, or microfoam sclerotherapy, meets the definition of medical necessity for symptomatic varicose veins/venous insufficiency when the following criteria have been met:

  1. Ulceration secondary to venous stasis; OR
  2. Recurrent superficial thrombophlebitis; OR
  3. Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity; OR
  4. 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 accessory saphenous veins by surgery, endovenous radiofrequency, laser ablation, or microfoam sclerotherapy that do not meet the criteria described above is considered cosmetic and does not meet the definition of medical necessity.

Symptomatic Varicose Tributaries

The following treatments meet the definition of medical necessity as a component of the treatment of symptomatic varicose tributaries when performed either at the same time or following prior treatment of the saphenous veins (none of these techniques has been shown to be superior to another):

Treatment of symptomatic varicose tributaries when performed either at the same time or following prior treatment of saphenous veins using any other techniques than noted above is considered experimental or investigational as there is insufficient clinical evidence to permit conclusions on efficacy and net health outcomes

Ultrasound guidance for sclerotherapy of the varicose tributaries does not meet the definition of medical necessity. There is insufficient scientific evidence in peer-reviewed medical literature that ultrasound guidance has been proven to increase the effectiveness or safety of sclerotherapy for these veins.

Perforator Veins

Surgical ligation (including subfascial endoscopic perforator surgery) or endovenous radiofrequency or laser ablation of incompetent perforator veins meets the definition of medical necessity as a treatment of leg ulcers associated with chronic venous insufficiency when ALL of the following conditions have been met:

Telangiectasia

Treatment of telangiectasia such as spider veins, angiomata, and hemangiomata is considered cosmetic and does not meet the definition of medical necessity.

Other

Techniques for conditions not specifically listed above are considered experimental or investigational, including, but not limited to:

The evidence is insufficient to permit conclusions on efficacy and net health outcomes.

* CEAP Clinical Classification System

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

S:

Symptoms including ache, pain, tightness, skin irritation, heaviness, muscle cramps, as well as other complaints attributable to venous dysfunction

A:

Asymptomatic

BILLING/CODING INFORMATION:

There are no specific CPT or HCPCS codes describing microfoam sclerotherapy (e.g. Varithena).

CPT Coding:

36468

Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk (non-covered)

36470

Injection of sclerosing solution; single vein

36471

Injection of sclerosing solution; multiple veins, same leg

36473

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated (Investigational)

36474

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) (Investigational)

36475

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated

36476

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

36478

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated

36479

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

37500

Vascular Endoscopy, surgical; with ligation of perforator veins, subfascial (SEPS)

37700

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

37718

Ligation, division, and stripping, short saphenous vein

37722

Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below

37735

Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer and skin graft and/or interruption of communicating veins of lower leg, with excision of deep fascia

37760

Ligation of perforator veins, subfascial, radical (Linton type), including skin graft, when performed, open, 1 leg

37761

Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg

37765

Stab phlebectomy of varicose veins, 1 extremity; 10 – 20 stab incisions

37766

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

37780

Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure)

37785

Ligation, division, and/or excision of varicose vein cluster(s), 1 leg

HCPCS Coding:

S2202

Echosclerotherapy

ICD-10 Diagnoses Codes That Support Medical Necessity:

I83.001 – I83.899

Varicose veins of lower extremities

I87.2

Venous, insufficiency (chronic) (peripheral)

LOINC Codes:

The following information may be required documentation to support medical necessity: Physician history and physical, attending physician treatment plan, progress notes, and treatment notes including documentation of symptoms, failure of at least 3 consecutive months of medical management, and radiology reports (if applicable).

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0,

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician visit notes

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology

18726-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

REIMBURSEMENT INFORMATION:

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

Procedure codes 36475 and 36476 include the imaging guidance. Separate payment will not be made for imaging guidance reported with procedure codes 36475 or 36476.

Procedure codes 36478 and 36479 include imaging guidance. Separate payment will not be made for imaging guidance billed with procedure codes 36478 or 36479.

Procedure code 37765 should be reported only once per leg.

Procedure code 37766 should be reported only once per leg.

Procedure codes 37765 and 37766 should not be reported together.

Note: Code 76970- Ultrasound Study follow-up (specify) is not an unlisted code. It is used to report a follow-up study after a previous ultrasound study has been completed. A description of the follow-up procedure should be included when reporting this code. Reimburse according to operative report.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products: The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Treatment of Varicose Veins of the Lower Extremity (L29298) located at fcso.com.

DEFINITIONS:

Accessory saphenous vein: A vein running in the thigh parallel to the great and small saphenous veins.

Angiomata: An abnormal growth due to the dilatation or new formation of blood vessels.

Cyanoacrylate adhesive: clear, free-flowing liquid that polymerizes in the vessel via an anionic mechanism (ie, polymerizes into a solid material upon contact with body fluids or tissue).

Great saphenous vein: the longest vein in the body, extending from the dorsum of the foot to just below the inguinal ligament, where it opens into the femoral vein. Also known as the long or large saphenous vein.

Hemangiomata: A benign tumor of blood vessels.

Small saphenous vein: the vein that continues the marginal vein from behind the malleolus and passes up the back of the leg to the knee joint, where it opens into the popliteal vein. Also known as the short or lesser saphenous vein.

Perforator veins: small veins that connect the superficial veins to the deep veins, allowing blood to drain from the skin into the deep veins and then pumped toward the heart.

Telangiectasia: a type of varicose veins also known as spider veins; small bluish-purple veins, usually found in clusters on the leg.

Tributaries: veins that empty into larger veins.

RELATED GUIDELINES:

Durable Medical Equipment (DME), 09-E0000-01
Reconstructive Surgery/Cosmetic Surgery, 02-12000-01

OTHER:

None Applicable

REFERENCES:

  1. American Venous Forum, Revision of the CEAP Classification: Summary; accessed at veinforum.org 12/30/15.
  2. Blue Cross Blue Shield Association. Medical Policy Reference Manual, 7.01.124, Treatment of Varicose Veins/Venous Insufficiency, 05/17.
  3. ECRI Health Technology Assessment Information Service. Windows on Medical Technology™. Endovenous Radio-Frequency Ablation (VNUS Closure® System) for the Treatment of Varicose Veins. August 2006. Issue No. 138, accessed at ecri.org 05/22/13.
  4. ECRI. Emerging Technology (TARGET) Report. Transilluminated powered phlebectomy (TIPP) for varicose veins. Plymouth Meeting, PA: ECRI. Updated 04/08/08.
  5. First Coast Service Options Inc. (FCSO) Local Coverage Determination (LCD) for Treatment of Varicose Veins of the Lower Extremity (L29298), accessed at fcso.com.
  6. Gloviczki P, Comerota AJ, et al, The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum, J Vasc Surg. 2011 May;53(5 Suppl):2S-48S; accessed at vascularweb.org 12/08/14.
  7. Hayes, Inc. HAYES Medical Technology Directory. Endoluminal Radiofrequency Ablation for Varicose Veins of the Leg. Lansdale, PA: Hayes, Inc.: May 2006.
  8. Hayes, Inc. HAYES Medical Technology Directory. Endovenous Laser Therapy for Varicose Veins of the Leg. Lansdale, PA: Hayes, Inc.: October 2006.
  9. Hayes, Inc. HAYES Medical Technology Directory. Sclerotherapy for Symptomatic Varicose Veins. Lansdale, PA: Hayes, Inc.: December 2004. Updated 12/29/06.
  10. Hayes, Inc. HAYES Medical Technology Directory. Transilluminated Powered Phlebectomy for Symptomatic Varicose Veins. Lansdale, PA: Hayes, Inc.: May 2002. Updated 04/26/06.
  11. Kalra M, Gloviczki P. Surgical treatment of venous ulcers: role of subfascial endoscopic perforator vein ligation. Surg Clin North Am. 2003 Jun; 83(3): 671-705.
  12. Kim HS, Paxton BE. Endovenous laser ablation of the great saphenous vein with a 980-nm diode laser in continuous mode: early treatment failures and successful repeat treatments. J Vasc Interv Radiol. 2006 Sep; 17(9): 1449-55.
  13. Medical Services Advisory Committee (MSAC). Endovenous laser treatment for varicose veins (ELT). Application 1113. Canberra: Medical Services Advisory Committee (MSAC). 2008. Medical Services Advisory Committee (MSAC).
  14. Michaels JA, Campbell WB, Brazier JE, Macintyre JB, Palfreyman SJ, Ratcliffe J, Rigby K. Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial). Health Technol Assess. 2006 Apr; 10(13): 1-196, iii-iv.
  15. National Guideline Clearinghouse (NGC) Guideline summary: ACR Appropriateness Criteria® radiologic management of lower-extremity venous insufficiency; accessed at guideline.gov 12/08/14.
  16. National Institute for Health and Clinical Excellence (NICE). Endovenous laser treatment of the long saphenous vein; Interventional Procedure Guidance 2004:2 accessed at nice.org 05/21/12.
  17. National Institute for Health and Clinical Excellence (NICE). Endovenous Mechanochemical Ablation for Varicose Veins, NICE interventional procedure guidance 435, 2016. Accessed at nice.org 05/08/17.
  18. National Institute for Health and Clinical Excellence (NICE). Radiofrequency ablation of varicose veins, Interventional Procedure Guidance, 2003 accessed at nice.org 05/21/12.
  19. National Institute for Health and Clinical Excellence (NICE). Subfascial endoscopic perforator vein surgery; Interventional Procedure Guidance, 2004:2 accessed at nice.org 05/21/12.
  20. National Institute for Health and Clinical Excellence (NICE). Transilluminated powered phlebectomy for varicose veins; Interventional Procedure Guidance 2004:2.
  21. National Institute for Health and Clinic Excellence (NICE). Ultrasound-guided foam sclerotherapy for varicose veins; Interventional Procedure Guidance, 2009, accessed at nice.org 05/21/12.
  22. National Institute for Health and Care Excellence (NICE). NICE Clinical Guideline 168: Varicose veins in the legs. 2013; accessed 12/08/14.
  23. New and Emerging Techniques Surgical. Australian Safety and Efficacy Register of New Interventional Procedures Surgical. Rapid Review. Subfascial Endoscopic Perforator Surgery (SEPS) for Chronic Venous Insufficiency. June 2003.
  24. O’Meara S, Cullum NA, Nelson EA. Compression for venous leg ulcers. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD000265. DOI:10.1002/14651858.CD000265.pub2.
  25. Rigby KA, Palfreyman SJ, Beverley C, Michaels JA. Surgery versus sclerotherapy for the treatment of varicose veins. Cochrane Database of Systematic Reviews 2004, Issue 4.
  26. Silberzweig JE, Funaki BS, et al. ACR Appropriateness Criteria® Treatment of Lower-Extremity Venous Insufficiency, 2009, accessed at guideline.gov 12/08/14.
  27. Society of Interventional Radiology. Position Statement. Endovenous Ablation. December 2003.
  28. Tawes RL, Wetter LA, Hermann GD, Fogarty TJ. Endoscopic technique for subfascial perforating vein interruption. J Endovasc Surg. 1996 Nov; 3(4): 414-20.
  29. Tenbrook JA Jr, Iafrati MD, O’donnell TF Jr, Wolf MP, Hoffman SN, Pauker SG, Lau J, Wong JB. Systematic review of outcomes after surgical management of venous disease incorporating subfascial endoscopic perforator surgery. J Vasc Surg. 2004 Mar; 39(3): 583-9.
  30. Tisi PV, Beverley C, Rees A. Injection sclerotherapy for varicose veins. Cochrane Database of Systematic Reviews 2006, Issue 4.
  31. U.S. Food and Drug Administration (FDA). VenaSeal Closure System – P140018, 2015; accessed at accessdata.fda.gov 12/30/15.
  32. van der Velden SK, Biemans AA, De Maeseneer MG, et al. Five-year results of a randomized clinical trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins. Br J Surg. Jul 1 2015.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 06/22/17.

GUIDELINE UPDATE INFORMATION:

02/15/02

04-77260-16 Endoluminal Radiofrequency Ablation for Varicose Veins approved.

07/15/02

Revised to remove limitation for sclerotherapy; Renamed to include other treatments for varicose veins; Renumbered from 04-77260-16 to 02-33000-13.

01/01/03

HCPCS coding update.

06/15/03

Reviewed; no change in coverage.

12/15/03

Sodium tetradecyl sulfate removed from MCG.

04/15/04

Review and revision of guideline consisting of updated references, added coverage statement for laser ablation, and added information about SEPS and Transilluminated Powered Phlebectomy (investigational). These additions led to the archiving of guideline: Subfascial Endoscopic Perforator Surgery (SEPS).

01/01/05

Annual HCPCS update; consisting of the deletion of S2130 and S2131 and addition of 36475, 36476, 36478 and 36479.

04/15/05

Review and revision of guideline; consisting of updated references, added coverage statement for Transilluminated powered phlebectomy.

04/15/06

Review and revision of guideline consisting of updated references.

11/15/06

Revision of guideline.

03/15/07

Review and revision of guideline consisting of updated references.

06/15/07

Reformatted guideline.

05/15/09

Biennial review: position statements and criteria revised; description section, reimbursement information, Medicare Advantage section and references updated.

01/01/10

Annual HCPCS coding review: added code 37761 & revised code descriptors for 37760 & 37765 located in the Program Exceptions section under the Medicare Advantage Products.

02/15/10

Revision: additional position statements added regarding sclerotherapy; reimbursement and definition sections updated.

10/15/10

Revision; related ICD-10 codes added.

02/15/11

Revision; formatting changes.

08/15/11

Revision; formatting changes.

10/01/11

Revision; formatting changes.

07/12/12

Annual review; position statements, billing/coding, Medicare program exception, and references updated; formatting changes.

10/15/12

Revision; Accessory saphenous veins position statement and definitions updated; formatting changes.

07/15/13

Annual review; position statement section and references updated; formatting changes.

05/15/14

Annual review; position statements maintained and references updated.

01/01/15

Annual HCPCS/CPT update. Removed code 36469.

02/15/15

Annual review; position statements and references updated; formatting changes.

10/01/15

Revision; ICD10 coding section updated.

11/01/15

Revision: ICD-9 Codes deleted.

02/15/16

Revision; description, position statement section and references updated; formatting changes.

03/23/16

Revision; reimbursement section updated.

05/15/16

Revision to Position Statement.

08/01/16

Revision: Reimbursement Section.

10/01/16

Revision; formatting changes.

01/01/17

Annual CPT/HCPCS update. Added 36473, 36474; revised 36476, 36479.

07/15/17

Revision; position statement section updated to incude CHIVA method; references updated.

Date Printed: October 20, 2017: 08:41 AM