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CurrentAetnaPolicy 0050

Varicose Veins

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Clinical coverage policy for diagnosis and treatment of varicose veins, including conservative therapy, sclerotherapy, endovenous ablation, phlebectomy, and related coding; applies to providers and claims under Aetna.

Policy Summary

PayerAetna

PolicyVaricose Veins

Policy CodePolicy 0050

Change TypeNo material changes

Effective DateNov 20, 1995

Last ReviewAug 3, 2026

Next Review DateJan 14, 2027

Key ActionDocument diagnostic duplex ultrasound confirming truncal reflux (eg, SFJ/SPJ reflux >0.5 sec) and prior conservative therapy when requesting authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120+references listed

08/03/2026last review

11/20/1995effective date

01/14/2027next review

4.5 mmGSV diameter threshold

>=0.5sreflux threshold

Coverage Criteria and Evidence-Based Considerations

General coverage approach

Covered when ALL of the following are met

Conservative therapy trial: Patient has undergone an adequate trial of conservative management (eg, appropriately fitted compression stockings, exercise, leg elevation, and lifestyle measures) for a reasonable duration unless urgent indication exists6+ months trial generally recommended

Authorities have recommended 6 or more months as a reasonable duration for conservative management

Objective reflux documented: Duplex or Doppler ultrasound documents primary venous reflux (eg, saphenofemoral or saphenopopliteal junction incompetence) with reflux duration greater than 0.5 seconds> 0.5 seconds

Duplex mapping is required to localize sources of incompetence and plan definitive therapy

Policy Summary

PayerAetna

PolicyVaricose Veins

Policy CodePolicy 0050

Change TypeNo material changes

Effective DateNov 20, 1995

Last ReviewAug 3, 2026

Next Review DateJan 14, 2027

Key ActionDocument diagnostic duplex ultrasound confirming truncal reflux (eg, SFJ/SPJ reflux >0.5 sec) and prior conservative therapy when requesting authorization.

SourceLink

On This Page

Procedure-appropriate anatomy:

Anatomic features suitable for the proposed intervention (examples: saphenous trunk diameter adequate for endovenous catheter insertion; very large varicosities may require operative excision)

GSV >= 4.5 mm for endovenous laser ablation; varicosities > 6 mm often require excision

Select therapy based on reflux source and vein size; small telangiectasias and non-refluxing small veins are cosmetic and not appropriate for ablative procedures

Symptomatic impact or complication: Symptoms significantly impair quality of life or there are complications (eg, symptomatic thrombophlebitis, venous ulceration) and conservative therapy has failed or is insufficientclinical judgment

Consider intervention earlier for complications such as ulceration where appropriate

Endovenous thermal ablation (ELAS/EVLA, RFA) — general indications

Covered when ALL of the following are met

Primary venous reflux documented: Clinically documented primary venous reflux of the great or small saphenous vein confirmed by duplex ultrasound

Duplex ultrasound mapping is required prior to endovenous catheter ablation

Vein anatomy suitable: Saphenous vein anatomy is suitable for catheter-based thermal ablation (catheter can be accommodated)>= 4.5 mm for ELAS

Endovenous laser ablation and RFA require a minimum saphenous vein diameter (ELAS not viable for veins <4.5 mm)

Conservative therapy trial: Conservative treatments have been exhausted and sclerotherapy is considered unlikely to succeed for truncal saphenous reflux

Document prior conservative management and rationale for endovenous thermal ablation

Subfascial endoscopic perforator surgery (SEPS) — role

Considered in select patients when ALL of the following are met

Advanced CVI with incompetent perforators: Patient has advanced chronic venous insufficiency (CVI) attributable to primary valvular incompetence of superficial and perforating veins, with or without deep venous incompetence

SEPS has been recommended for patients with advanced CVI secondary to primary valvular incompetence while awaiting higher-quality randomized data

No contraindications to SEPS: No absolute contraindications to SEPS are present (eg, occlusive arterial disease, infected ulcer, non-ambulatory status, medically high-risk conditions)

Relative contraindications include diabetes, renal or liver failure, morbid obesity, and deep vein obstruction; suitability should be determined case-by-case

Foam sclerotherapy / polidocanol (Varithena) — role and limitations

Coverage stance and considerations

Indicated for certain varicosities: Ultrasound-guided foam sclerotherapy (including polidocanol foam/Varithena) is indicated for treatment of incompetent GSV, accessory saphenous veins and visible varicosities of the GSV system and improves symptoms and appearance per FDA labeling for Varithena

Long-term durability for junctional reflux is less well-established and comparative data versus ablation are limited

Comparative effectiveness: Randomized trials report lower complete ablation rates at 6 months and higher technical failure with foam versus laser or surgery in some studies; foam may have faster recovery but variable recurrence and higher rates of lumpiness/staining

Brittenden RCT and polidocanol microfoam trials inform comparative outcomes and adverse-event profiles

Evidence-supported clinical scenarios — CAC in adult patients with symptomatic truncal saphenous vein reflux

Clinical evidence supports use of CAC in adult patients with symptomatic truncal saphenous vein reflux under the following study-based conditions:

Study-based eligibility: Adults (>=18 years) with symptomatic varicose veins and truncal saphenous reflux (CEAP C2–C6 in many trials) with duplex-confirmed reflux criteria (eg, SFJ/SPJ reflux > 0.5 seconds in included studies)as reported in source trials

Derived from eligibility criteria used across systematic reviews and randomized trials of cyanoacrylate closure

Clinical evidence for cyanoacrylate endovenous ablation

Evidence summary and outcome findings from clinical studies and systematic reviews

Effectiveness outcomes: Multiple prospective, randomized, and retrospective studies report high early-to-mid-term target vein closure/occlusion rates for cyanoacrylate techniques (typical mid-90% occlusion at 6–36 months) with sustained improvements in venous clinical scores and quality-of-life measuresTypical 6–36 month closure rates ~94–97% in RCTs and cohort series

Supported by VeClose RCT, systematic reviews, and multiple single-center series

Comparative outcomes: Randomized trials and meta-analyses demonstrate non-inferiority of cyanoacrylate closure (CAC) versus RFA/EVLA for anatomical closure at multiple timepoints and similar clinical QOL improvements; CAC may have shorter procedure time and reduced peri-procedural pain in some studies

Evidence includes VeClose RCT, network meta-analyses, and comparative cohorts

Safety and adverse events: Common adverse events include phlebitis, ecchymosis and retained coagulum; hypersensitivity and prolonged thrombophlebitis have been reported (including series with notable prolonged thrombophlebitis when combined with STS), and deep venous extension is rare but documented

Reported AE rates vary across studies (eg, phlebitis reported in multiple series; prolonged thrombophlebitis up to 38.5% in one combined therapy series)

Operational advantages: Cyanoacrylate techniques typically do not require tumescent anesthesia, may have shorter procedure times, and may enable faster return-to-work compared with thermal ablation in some cohorts

Procedure time and pain differences reported in comparative studies (eg, shorter operative time and less peri-procedural pain with CA in several series)

Limitations of evidence: Many studies are single-center, retrospective, or have limited sample size and follow-up; ongoing larger randomized trials will better define long-term comparative durability

Longer-term data and larger multicenter RCTs (eg, Spectrum) are needed to confirm durability beyond mid-term follow-up

Evidence-based coverage considerations (informational)

Evidence-supported coverage considerations based on trial populations and outcomes

Clinical indication: Symptomatic incompetence of the great or small saphenous vein (and selected incompetent perforators) as treated in cited trials and series

Trials included symptomatic GSV/SSV and some studies included perforator interventions

Reported acceptable outcomes: Short- and mid-term anatomic closure rates and clinical improvements used in trials demonstrate outcomes often comparable to thermal ablation (eg, CAC 24–36 month closure ~94–95%), which can inform coverage assessmentsclosure ≥90% reported in many series; CAC 24–36 month closure ~94–95% in RCTs

Use trial-based closure and clinical outcome metrics when evaluating case-specific medical necessity

Safety and adverse events: Assess and document known risks including phlebitis, prolonged thrombophlebitis, rare hypersensitivity reactions, and rare deep venous extension when present

Adverse event profiles vary; prolonged thrombophlebitis and deep venous extension have been reported in some series

Follow-up requirements: Post-procedure duplex ultrasound and clinical outcome assessments (eg, VCSS, AVVQ, EQ-5D) at serial intervals as used in trials (day 3; 1, 3, 6, 12, 24, 36 months) support evaluation of anatomical success and durability

Many studies mandated serial DUS assessments up to 36 months

Evidence-informed coverage considerations — non-formalized considerations

Coverage considerations informed by the evidence (not formalized criteria in this section):

Evidence-informed coverage considerations: 1) Symptomatic superficial venous insufficiency of GSV or SSV with duplex-documented reflux; 2) Documentation of baseline vein diameter and planned duplex follow-up using a defined anatomical success metric; 3) Patient preference or clinical scenarios where thermal ablation is problematic (eg, tortuous or superficial trunks, below-knee disease) may support consideration of MOCA or CAC; 4) Recognize limited long-term randomized data and potential for decreased occlusion over long follow-up

These are informational considerations derived from cohort, registry and assessment reports, not prescriptive coverage rules

MOCA / CAC comparative outcomes — summary findings

Summary findings from technology assessment and studies

MOCA (Clarivein) evidence summary: MOCA demonstrates high short-term anatomical success (pooled ~90%+) with low major complication rates but yields slightly higher re-canalization and somewhat lower long-term anatomical success compared with thermal ablation in some analyses; clinical symptom and QOL improvements are often similar to thermal methods

Ontario Health assessment and pooled MOCA reviews support these conclusions; long-term AS may decline over years in some cohorts

Electrostimulation (VeinOPlus) evidence

VeinOPlus (electrostimulation) findings

VeinOPlus EMS outcomes: Electrostimulation (VeinOPlus) studies report symptom reduction, decreased edema, improved VCSS and quality-of-life scores, and in small non-randomized studies reduced postoperative DVT incidence when added to compression and low‑dose heparinstudies are small and non-randomized

Promising adjunctive therapy but evidence from RCTs is lacking and confirmation is needed

Molecular markers — investigational biomarkers

Investigational biomarkers

MMP genotyping: Genotyping of MMP promoter polymorphisms (eg, MMP1, MMP2, MMP3, MMP7) has not demonstrated association with varicose vein risk in multiple studiesno associations found in studied cohorts

Not useful as predictive clinical markers based on current evidence

Growth factor plasma levels: Small studies show altered plasma levels of growth factors (ANG1, EGF, PDGF, VEGF) in patients pre-operatively that normalize after EVLA, suggesting pathophysiologic relevance but only preliminary prognostic datasmall sample sizes

Preliminary research only; not established for clinical use

Evidence summaries relevant to coverage

Evidence and considerations summarized (no explicit must-meet coverage checklist in these excerpts):

EVLA vs Surgery findings: Systematic reviews and meta-analyses show comparable clinical effectiveness between EVLA/RFA and conventional surgery for many outcomes; surgery may have higher technical success at 2 years while EVLA/RFA have fewer postoperative complications

Use these comparative findings to contextualize modality selection and surgical alternatives

Tributary treatment strategies: Randomized trials (eg, FinnTrunk) are evaluating concomitant versus staged treatment of tributaries with truncal ablation; record planned follow-up and PROMs when considering combined approaches

Consider trial designs and follow-up schedules when assessing additional tributary procedures

Pharmacological thromboprophylaxis: VTE risk among endovenous intervention study subjects is heterogeneous; individualized risk stratification is important to guide peri-procedural pharmacological prophylaxis

Document Caprini or other risk assessment when prophylaxis is used or omitted

Post-operative scanning after RFA: Retrospective data indicate routine post-operative duplex scanning after RFA rarely changes management (>99% of cases); routine scans without clinical indication may be unnecessary

Reserve post-op DUS for clinical indications or protocolized follow-up rather than routine scanning

Visible subcuticular veins (spider angiomas and telangiectasias) measuring less than 2.5 mm do not cause symptoms and their treatment is considered purely cosmetic; interventions for these small superficial veins are not medically necessary and are excluded from coverage. [

The diagnosis code I87.2 (venous insufficiency, chronic) is explicitly not covered when used to indicate reflux involving the saphenopopliteal junction, common femoral vein, or iliac veins; claims for those anatomic reflux sites should not be adjudicated under I87.2 per the policy guidance.

Endovenous laser ablation and some sclerotherapy techniques are not appropriate for very small superficial veins. A catheter-based thermal approach requires a lumen large enough for device insertion and is not viable for saphenous veins smaller than 4.5 mm, and telangiectases/reticular veins should be managed with sclerotherapy or ambulatory phlebectomy when indicated; treatment of small asymptomatic veins remains cosmetic.

Available randomized trials and systematic reviews are heterogeneous with respect to compression products, duration, and outcomes. The literature does not support a single standardized post‑treatment compression regimen; there is insufficient evidence to mandate a specific compression protocol after venous interventions. Clinical judgment and local practice should guide compression use.

Appropriate Use Criteria (AUC) developed by professional societies identify several scenarios rated as "never appropriate", for example treatment of saphenous veins with no documented reflux and incidental iliac or inferior vena cava stenting for minimal or no symptoms. Performing procedures in these AUC-classified scenarios may be inappropriate and subject to utilization review.

Many randomized trials and comparative studies applied exclusion criteria that limit generalizability. Common exclusions in trials included recurrent varicose veins, current deep venous thrombosis (DVT), or serious arterial disease; these conditions were often grounds for trial exclusion and warrant individualized clinical evaluation before considering cyanoacrylate or other endovenous therapies.

At least one comparative series excluded patients with active venous leg ulcers; consequently, evidence from those studies does not directly address effectiveness or safety in patients with ulceration and should be interpreted cautiously when applied to that population.

Some studies combined cyanoacrylate ablation with adjunctive sclerotherapy (or other concurrent treatments), which can confound interpretation of efficacy and safety outcomes. Small sample sizes and short follow-up in these combined-treatment reports limit confidence in attributing results to a single modality.

Several series excluded patients receiving oral anticoagulants and reported limited data on MOCA effectiveness among anticoagulated patients. Evidence addressing outcomes of MOCA in patients on anticoagulation is therefore limited, and anticoagulation status should be considered when assessing candidacy and expected outcomes.

The body of evidence includes many small cohorts, single‑center series, and studies with short follow‑up or incomplete retention. These methodological limitations—small sample sizes, variable follow‑up duration, heterogeneity in outcome definitions, and loss to follow‑up—reduce the certainty and generalizability of comparative effectiveness findings.

A systematic review and technology assessments did not identify published head‑to‑head studies comparing MOCA directly with cyanoacrylate adhesive closure (CAC), nor comparisons of non‑thermal endovenous procedures with less common vein‑sparing approaches (for example CHIVA); such direct comparative data are absent in the reviewed literature.

Retrospective data indicate that routine post‑operative duplex scanning after radiofrequency ablation rarely changes patient management; one series found routine scans did not change management in over 99% of cases, suggesting routine post‑op scanning without clinical indication is low‑yield.

Sclerotherapy alone is not appropriate for treating junctional reflux; when reflux originates at the saphenofemoral or saphenopopliteal junctions, the junction must be addressed by ligation or endovenous ablation before or in conjunction with sclerotherapy—sclerotherapy should not be used as a standalone treatment for junctional incompetence.

Treatment of small veins and telangiectasias performed solely for cosmetic reasons is not medically necessary. FDA labeling and guideline reviews note that tiny spider veins (for example <1–2.5 mm) do not cause symptoms; interventions aimed at appearance alone are considered cosmetic and excluded.

Long‑term comparative effectiveness and recurrence prevention remain uncertain for several non‑thermal and chemical modalities. Some registries and long‑term cohorts report declining anatomical success over many years (for example MOCA series), and systematic reviews note variable durability across techniques, so long‑term superiority for recurrence prevention is not established.

A randomized trial of MOCA using ClariVein found that when combined with 1% polidocanol microfoam the anatomical success was substantially lower versus higher concentration liquid formulations; the authors concluded MOCA with 1% microfoam was significantly less effective and should not be considered for truncal vein incompetence.

The excerpts do not include any explicit, broad statements declaring cyanoacrylate, MOCA, or other newer non‑thermal procedures universally not medically necessary. However, the document repeatedly notes the absence of adequate long‑term data and heterogeneous outcome definitions, which may limit coverage decisions in contexts where durable long‑term effectiveness must be demonstrated.

Genotyping promoter polymorphisms in matrix metalloproteinase genes (MMP1, MMP2, MMP3, MMP7) has not been shown to be associated with varicose vein susceptibility in multiple studies and thus is not supported as a useful clinical marker for patient selection or risk stratification.

Applicable Coding and Measurement Thresholds

Applicable CPT / HCPCS codesmixed

36468	Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk
36473	Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated
36474	Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated
37204	Transcatheter occlusion or embolization, percutaneous, non-CNS, non-head/neck
37241	Vascular embolization or occlusion; venous, other than hemorrhage
37244	Vascular embolization or occlusion; for arterial or venous hemorrhage or lymphatic extravasation
75894	Transcatheter therapy, embolization, any method, radiological supervision and interpretation
76942	Ultrasonic guidance for needle placement (not covered when performed solely to guide needle or introduce the sclerosant into the varicose veins)
76998	Ultrasonic guidance, intraoperative (not covered when performed solely to guide needle or introduce the sclerosant into the varicose veins)
37252	Intravascular ultrasound (noncoronary vessel), initial noncoronary vessel

1–10 of 19

1/2

Applicable ICD-10 codesICD-10

I80.00-I80.03	Phlebitis and thrombophlebitis of superficial vessels of lower extremities
I82.401-I82.499	Acute embolism and thrombosis of deep veins of lower extremity
I82.501-I82.599	Chronic embolism and thrombosis of deep veins of lower extremity
I83.001-I83.899	Varicose veins of lower extremities
I87.001-I87.099	Postthrombotic syndrome
I87.2	Venous insufficiency (chronic) (peripheral) [not covered for saphenopopliteal reflux; not covered for common femoral reflux; not covered for reflux of iliac veins]
I83.90-I83.93	Asymptomatic varicose veins of lower extremities
M62.50-M62.59	Muscle wasting and atrophy, not elsewhere classified
M62.5A0-M62.5A9	Muscle wasting and atrophy, not elsewhere classified
O22.00-O22.03	Varicose veins of lower extremity in pregnancy

1–10 of 15

1/2

No CPT/HCPCS/ICD codes listed in this excerptmixed

No codes listed

Covered CPT Codes, Not Covered, Experimental, Cosmetic, Presumptivemixed

No codes listed

Reflux duration and GSV diameter — key thresholds

Reflux duration thresholdReflux > 0.5 seconds (documented by Doppler or Duplex) — used as a criterion for ligation/ablation

GSV diameter measurement siteGSV diameter recorded 2.5 cm distal to the saphenofemoral junction

ELAS suitability diameterEndovenous laser ablation requires saphenous vein diameter ≥ 4.5 mm

Operative excision size guidanceOperative excision reserved for very large varicosities (>6 mm) or extensive clusters

Cosmetic exclusion sizeVisible subcuticular veins (spider angiomas, telangiectasias) < 2.5 mm considered cosmetic

Minimum vein diameter for endovenous catheter

Minimum vein diameter for endovenous catheter insertion≥ 4.5 mm — ELAS/EVLA not viable for saphenous veins smaller than 4.5 mm

Alternative treatment for smaller veinsSmaller veins may be treated with sclerotherapy or ambulatory phlebectomy

Catheter requirement rationaleA catheter must be inserted into the lumen of the vein to perform endovenous laser treatment

Target vein diameter predictor for re-canalization

Target vein diameter predictive cutoff>= 9.5 mm predicts re-canalization (sensitivity 81%, specificity 75%)

Outcome associationLarger target vein diameter (≥9.5 mm) associated with higher re-canalization at 18 months in single-center series

Implication for treatment planningConsider alternative techniques or modified protocols for veins ≥9.5 mm to reduce re-canalization risk

Follow-up duration example (long-term MOCA cohort)

Example long-term follow-up durationMean 8.4 ± 0.9 years (range 5.5 to 10.3 years) — reported in a prospective single-center Clarivein MOCA cohort

Anatomical success at long-term follow-upAnatomical success (AS) observed in 60.5% of limbs at mean 8.4-year follow-up

Clinical outcome changesVenous Clinical Severity Score (VCSS) and QOL scores improved overall, with greater improvement when AS achieved

Prior Authorization, Documentation, and Operational Requirements

Prior Authorization

Enumerated CPT/HCPCS codes may require authorization

Codes enumerated in the policy are listed as applicable to these procedures and may be subject to prior authorization or coding review; ultrasound guidance codes (76942, 76998) are noted as not covered when performed solely to guide needle placement or introduce sclerosant.

Applicable procedure/CPT/HCPCS codes include 36468, 36473, 36474, 37204, 37241, 37244, 75894, 76942, 76998, 37252, 75820, 75822, 93922, 93923, 93924, 93970, 93971, S2202, A6530–A6549.

Documentation Required

Confirm duplex‑documented primary reflux and prior conservative therapy

Before performing endovenous ablative procedures, confirm clinically documented primary venous reflux with duplex ultrasound and document that conservative measures (eg, compression stockings, lifestyle measures) and sclerotherapy are unlikely to succeed.

Document duplex-confirmed primary venous reflux (eg, SFJ/SPJ reflux >0.5 sec).
Document prior conservative management (authorities recommend a trial of ≧6 months unless urgent).

Documentation Required

Document duplex follow‑up schedule and operator training/proctoring

Include duplex ultrasound mapping and plan for serial duplex follow‑up as used in trials (day 3, 1, 3, 6, 12 months and beyond) and retain evidence of operator training/proctoring (FDA required proctored roll‑in cases for VenaSeal) when applicable.

Record baseline DUS localization and measurements (eg, reflux duration, GSV diameter).
Document planned post‑procedure DUS timepoints (eg, day 3; 1, 3, 6, 12 months) and any roll‑in/proctoring training completed (first 2 cases per FDA for VenaSeal).

Note

Cite AUC when supporting medical necessity

Use published Appropriate Use Criteria (AUC) to support medical‑necessity determinations; procedures performed in scenarios rated 'never appropriate' (eg, treatment of saphenous veins with no reflux) may receive increased utilization scrutiny.

Reference AUC scenario ratings when justifying intervention and imaging utilization.

Prior Authorization

Provide clinician training and governance evidence for CA procedures

Be prepared to provide evidence of clinician training and institutional governance for cyanoacrylate procedures (clinical governance, consent, audit), as guidance documents recommend procedures be performed by trained clinicians experienced with venous ultrasound.

Document clinician training and experience in endovenous techniques and venous ultrasound.
Document local clinical governance, consent processes, and audit arrangements if requested.
Note: FDA required proctoring for early VenaSeal adopters (first 2 cases).

Note

No explicit prior‑authorization rules for CAC in this excerpt

The policy excerpts do not specify a formal prior‑authorization program or explicit PA code list for cyanoacrylate ablation systems in this section; refer to the main policy/plan administrative procedures for exact PA rules.

No explicit PA requirements or affected billing codes are stated in the provided text for CAC.
Consult plan-specific prior authorization resources or Clinical Policy Bulletin Notes for administrative PA steps.

Prior Authorization

Include indication and planned duplex follow‑up in authorization requests

When requesting authorization, include the indication (eg, symptomatic GSV incompetence with duplex confirmation) and a planned follow‑up schedule or evidence of trial enrollment used in clinical studies (serial DUS assessments up to 36 months where applicable).

Specify symptomatic diagnosis and DUS findings (eg, reflux >0.5 sec).
Provide planned post‑procedure duplex schedule (eg, day 3; 1, 3, 6, 12, 24, 36 months) as used in trials.

Prior Authorization

Prior authorization may require baseline DUS and long‑term outcome plan

If long‑term outcomes are relevant to coverage, prior authorization may require submission of baseline duplex imaging and a planned long‑term imaging/outcomes schedule because evidence and outcome definitions are heterogeneous and long‑term data vary by modality.

Include baseline DUS and planned follow‑up timepoints to demonstrate intent to track anatomical success/durability.
Provide clinical rationale if long‑term durability data are being requested for coverage decisions.

Note

Evidence summaries available but no specific PA codes for MOCA/CAC

The document summarizes evidence for MOCA and CAC and provides clinical guidance, but does not list specific PA codes or a distinct PA algorithm for MOCA/CAC in these sections; use the evidence summaries to support case‑specific PA requests where required.

Use trial evidence summaries (RCTs and cohort data) to justify medical necessity.
There is no explicit PA code‑level guidance for MOCA/CAC provided in the excerpt.

Documentation Required

Document thromboprophylaxis plan and VTE risk assessment

Document whether pharmacologic thromboprophylaxis is planned and the individualized VTE risk assessment (eg, Caprini score), since peri‑procedural prophylaxis practices vary and risk stratification influences prophylaxis decisions.

Record pre‑operative VTE risk assessment (eg, Caprini) in the chart.
State whether pharmacologic prophylaxis will be used and the rationale for use or omission.

Documentation Required

Justify routine post‑op imaging and prophylaxis with documented clinical indications

Provide clinical justification for any routine postoperative duplex imaging or thromboprophylaxis beyond standard practice; retrospective data show routine post‑op scans after RFA rarely change management and prophylaxis should be individualized based on risk.

If ordering routine post‑procedure DUS, document specific clinical indications because routine scans seldom altered management in retrospective series.
Justify pharmacologic prophylaxis decisions with documented risk stratification.

Note

No prior‑authorization codes listed in references section

References section and some document segments do not list any specific prior authorization codes or requirements; follow the main policy sections and plan administrative guidance for PA implementation.

No PA codes appear in the references portion; consult main policy for PA procedures.

Note

No PA specified in this section — refer to main policy

This section does not state prior authorization rules—providers must refer to the main policy and plan administrative materials for any applicable authorization steps.

No PA requirements are described in this excerpt; check plan resources for PA procedures.

Step Therapy

Document trial of conservative therapy (typically ≥6 months) before intervention

Conservative management (eg, appropriately fitted compression stockings, exercise, leg elevation) should be tried first and documented; authorities recommend a 6+ month trial of conservative therapy unless urgent indications exist.

Document duration and type of conservative measures used (compression hosiery fit, exercise/lifestyle counseling).
Note exceptions when urgent intervention is clinically indicated.

Documentation Required

Document failed conservative/sclerotherapy before endovenous procedures

Document that conservative treatments have been exhausted and that sclerotherapy is unlikely to succeed for truncal varicose veins before endovenous procedures are performed.

Record prior sclerotherapy attempts and rationale why sclerotherapy is unlikely to succeed for the target truncal vein.
Confirm conservative therapy failure in the clinical record.

Billing Rule

Document rationale if choosing non‑thermal modality over EVLA/ETA

When modality selection is being considered, recognize that cost‑effectiveness analyses and guidelines have favored endothermal ablation (EVLA/ETA) as cost‑effective for suitable patients; document clinical rationale when choosing alternative modalities.

If selecting non‑thermal modalities, document clinical reasons (eg, tortuous or superficial veins, patient preference, contraindication to tumescent anesthesia).
Be aware cost‑effectiveness analyses informed guideline recommendations favoring ETA for many patients.

Step Therapy

No mandated step‑therapy sequencing — individualize modality selection

Select treatment modality individualized to the patient; the provided text does not mandate a step‑therapy sequence or required sequencing among thermal, non‑thermal, or chemical options.

There is no mandated payer step‑therapy sequence in the excerpt; document the individualized clinical rationale for modality choice.

Documentation Required

Document consideration of established alternatives before novel non‑thermal options

Consider standard alternative therapies (EVLA, RFA, UGFS) when documenting treatment choice for CAC; comparative trials are ongoing and payers may consider established therapies first‑line until equivalent long‑term outcomes are demonstrated for newer non‑thermal options.

Document prior consideration of thermal ablation or reason for selecting CAC/MOCA instead.
Note ongoing trials comparing non‑thermal to thermal modalities (eg, LAMA, Spectrum).

Step Therapy

No payer step‑therapy mandated in these excerpts

No explicit step‑therapy or sequencing requirements are described in the provided excerpts; do not assume a payer‑mandated sequence unless specified by the main policy or plan administrative rules.

If a jurisdiction requires compression first‑line, document prior conservative therapy accordingly.
For payer sequencing questions, consult plan PA/step‑therapy rules.

Note

Documentation Required

Obtain and document pre‑treatment Doppler/duplex mapping and measurements

Pre‑treatment Doppler or duplex ultrasound must be performed to localize sources of incompetence and to record reflux duration and GSV diameter (eg, reflux >0.5 sec; measure GSV 2.5 cm distal to SFJ), which are required to plan appropriate therapy.

Record reflux duration (eg, >0.5 seconds) and GSV diameter measured 2.5 cm distal to the saphenofemoral junction.
Use DUS mapping to individualize the treatment strategy and document target anatomy.

Documentation Required

Document duplex mapping confirming primary venous reflux before procedure

Document duplex ultrasound mapping that confirms primary venous reflux and the site/extent of saphenous reflux prior to endovenous procedures; ultrasound is imperative during catheter placement and for tumescent anesthesia administration.

Include duplex confirmation of truncal reflux (eg, SFJ/SPJ incompetence) in the chart.
Document intra‑procedural ultrasound guidance used for catheter placement and tumescent infiltration where applicable.

Documentation Required

Document protocolized post‑procedure duplex and outcome measures

Capture objective outcome imaging used in trials: document duplex ultrasound confirmation of target vein closure at trial timepoints (day 3; 1, 3, 6, and 12 months) and record adverse events, VCSS, and quality‑of‑life scores to support outcomes assessment.

Schedule and document DUS at early and serial post‑procedure intervals (eg, day 3; 1, 3, 6, 12 months).
Record VCSS and validated PROMs (eg, AVVQ, EQ‑5D) as available to support outcomes reporting.

Documentation Required

Document informed consent and planned follow‑up for long‑term outcomes

Document informed consent that addresses the procedure, potential foreign‑body reactions, need for serial follow‑up, and plans for long‑term outcome collection; retain follow‑up plans consistent with trial designs where applicable.

Document that patients were informed about risks (eg, phlebitis, hypersensitivity, possible recanalization) and the planned follow‑up schedule.
Retain documentation of patient‑reported outcomes collection if enrolled in trials or for outcomes tracking.

Documentation Required

Include DUS evidence of truncal reflux and CEAP classification in clinical documentation

Document diagnostic duplex demonstrating truncal/tracer reflux (example: SFJ/SPJ incompetence with reflux >0.5 seconds) and record CEAP class, procedural details, and planned follow‑up assessments to support medical necessity.

Include objective DUS metrics (reflux duration >0.5 sec) and GSV diameter in the pre‑op record.
Record CEAP classification, procedure type, and planned imaging/timepoints.

Documentation Required

Record post‑procedure DUS and clinical outcome scores at serial intervals

Document duplex ultrasound assessments of target vein closure at post‑procedure timepoints (eg, 1, 3, 6, 12, 24, 36 months) and record VCSS and quality‑of‑life measures as done in clinical trials to support durability claims.

Use serial DUS to document anatomic success and record PROMs (AVVQ, EQ‑5D‑5L, VCSS) at follow‑up visits.
Retain records of any adjunctive procedures and re‑interventions.

Documentation Required

Define and document anatomical success metric and DUS follow‑up findings

Document anatomical success definitions and duplex follow‑up results (occlusion vs. length of re‑canalization) because heterogeneity in definitions influenced reported outcomes; specify the metric used (eg, complete occlusion, re‑canalized segment <10 cm, % occlusion).

State the anatomical success definition used for the patient (eg, complete occlusion or re‑canalized segment <10 cm).
Document DUS findings against that predefined metric at each follow‑up visit.

Documentation Required

Record duplex results, re‑canalization, and PROMs in follow‑up notes

Clinical follow‑up documentation used in studies includes duplex ultrasound and patient‑reported outcomes; record technical success, any re‑canalization, and VCSS/QOL changes to support clinical effectiveness reporting.

Document technical success at the procedure and any subsequent re‑canalization on DUS.
Record changes in VCSS and disease‑specific QOL instruments over follow‑up.

Documentation Required

Document pre‑op VTE risk assessment and thromboprophylaxis rationale

Perform and document a pre‑operative VTE risk assessment (eg, Caprini score) and the rationale for use or omission of pharmacologic thromboprophylaxis, since guidelines recommend selective prophylaxis after individualized risk assessment.

Include Caprini (or equivalent) score in the pre‑op evaluation.
Document prophylaxis plan and reasoning (mechanical only versus addition of pharmacologic agents).

Documentation Required

Prospectively document outcome measures and DUS for tributary treatment trials

For trials comparing tributary treatment strategies, prospectively document baseline CEAP class, PROMs (AVVQ, VCSS, EQ‑5D‑5L), numeric pain scores, analgesic use, DUS findings, and any additional procedures to support study endpoints.

Collect and chart baseline CEAP, validated PROMs, and serial DUS findings.
Record analgesic use and any adjunctive interventions during follow‑up.

Note

Reference policy history and Clinical Policy Bulletin Notes for administrative guidance

Refer to the policy history and Clinical Policy Bulletin Notes when administrative or documentation questions arise; the policy's last review and next review dates are provided for reference.

Policy last reviewed 08/03/2026; next review 01/14/2027.
Clinical Policy Bulletin Notes and Review History links are available for administrative guidance.

Billing Rule

Follow enumerated coding and note restrictions on ultrasound‑guidance codes

Use the listed CPT/HCPCS/ICD codes exactly as enumerated in the policy when submitting claims; be aware that use of ultrasound‑guidance codes (76942, 76998) solely to guide sclerosant injections may be restricted and could trigger coding denials.

Submit applicable codes (eg, 36468; 36473/36474; 37204/37241/37244; 93970/93971; S2202; A6530–A6549) as appropriate to the service.
Avoid billing 76942/76998 when the ultrasound is performed solely to guide needle placement for sclerotherapy, per policy note.

Denial Risk

Record GSV diameter; note ELAS requires ≥4.5 mm

Measure and document GSV diameter (eg, 2.5 cm distal to the saphenofemoral junction); endovenous laser ablation requires a minimum saphenous vein diameter of ≧4.5 mm and procedures on smaller veins may be considered inappropriate.

Record GSV diameter measurement in the pre‑op duplex report.
If GSV diameter <4.5 mm, document rationale if an endovenous laser procedure is still being considered.

Denial Risk

Incomplete DUS follow‑up or missing closure data may prompt denials

Missing objective closure data or failure to meet study‑style follow‑up (serial DUS) can affect assessment of effectiveness; absence of documented DUS outcomes or incomplete follow‑up may increase risk of coverage denial or audit.

Ensure serial DUS results and outcome metrics are entered in the medical record.
Document reasons for any missed follow‑up visits and any attempts to obtain DUS assessments.

Denial Risk

Ensure clinician qualifications and ultrasound experience are documented

Perform procedures only when supported by documented clinician qualifications and ultrasound experience; lacking documentation of appropriate training and venous ultrasound experience could trigger denial or audit.

Document clinician credentialing/training and any proctored cases (eg, VenaSeal roll‑in cases).
Maintain records of institutional governance and competence assessments.

Denial Risk

Limited long‑term durability data for CA may trigger coverage questions

Limited long‑term durability data for cyanoacrylate glue are noted in the evidence; when payers require long‑term durability for coverage, absence of long‑term data may lead to coverage challenges—document follow‑up plans and available mid‑term outcomes.

Provide available mid‑term/long‑term trial outcomes (eg, VeClose 24–36‑month closure rates) to support durability claims.
Document planned surveillance and re‑intervention thresholds.

Denial Risk

Evidence heterogeneity and incomplete follow‑up may prompt denials

Heterogeneity in outcome definitions, variable follow‑up completeness, and limited long‑term randomized data are evidence limitations that payers may cite when denying coverage for long‑term durability claims; include standardized DUS metrics and follow‑up documentation to mitigate this risk.

Use predefined anatomical success metrics (eg, complete occlusion or re‑canalized segment <10 cm) and document accordingly.
Provide trial‑based outcome data and patient‑specific follow‑up to address evidence gaps.

Documentation Required

Document individualized VTE risk assessment to support prophylaxis decisions

Failure to perform or document individualized VTE risk assessment (eg, Caprini score) may affect peri‑procedural prophylaxis decisions and could be cited in case reviews; document the assessment and prophylaxis rationale.

Include Caprini score in the pre‑op record and document whether pharmacologic prophylaxis will be used.
If prophylaxis is omitted, record the clinical rationale based on the individualized risk assessment.

Denial Risk

Avoid routine post‑op scans without clinical justification

Routine postoperative scanning after RFA rarely changed management in a retrospective series; routine post‑op scans without documented clinical indication could be considered low‑value and may be challenged by payers.

If ordering routine post‑procedure DUS, document clinical justification since retrospective data suggest scans seldom altered management.
Limit routine scans to cases with specific clinical indications or abnormal symptoms.

Note

Clinical Policy Bulletins are administrative guidance — follow plan rules

Clinical Policy Bulletins assist plan administration but do not constitute a contract; providers remain responsible for treatment decisions and for following plan billing and authorization procedures.

Consult plan administrative materials for contractual billing and authorization requirements.
Retain documentation that supports medical necessity and coding submissions.

Note

Background and Epidemiology

Varicose veins are a common condition; a substantial proportion of affected individuals are asymptomatic and many respond to conservative measures. Conservative therapies—well‑fitted compression stockings, exercise, and leg elevation—are effective for many patients, and authorities commonly recommend a trial of conservative management for approximately 6 months before elective invasive interventions when symptoms allow.

Definitions and Key Terms

Endovenous catheter ablation (EVCA / ELAS)

DefinitionMinimally invasive thermal catheter-based destruction of refluxing saphenous vein segments (laser or radiofrequency) performed under duplex guidance

Typical indicationsUsed for patients with clinically documented primary venous reflux confirmed by duplex when conservative therapy has failed

Procedural elementsCatheter introduced into the vein lumen with ultrasound guidance; thermal energy applied to collapse and seal the vein; usually performed under tumescent anesthesia

Ambulatory phlebectomy (AP)

DefinitionMinimally invasive outpatient excision of surface varicose veins under local anesthesia (also called microphlebectomy)

IndicationEffective for non‑refluxing superficial varicosities but recurrence is likely if source reflux is not treated

Typical settingOutpatient procedure allowing immediate ambulation; may require compression pads post-procedure

Sclerotherapy

DefinitionInjection of sclerosing solutions (chemical ablation) for small-to-moderate varicose veins and telangiectasias

LimitationsNot appropriate as sole treatment for junctional reflux; large varicosities (>6 mm) respond less well

Cosmetic useTreatment of spider veins/telangiectasias <2.5 mm is considered cosmetic

Tumescent anesthesia

DefinitionLocal anesthetic technique using large volumes of dilute lidocaine (tumescent anesthesia) to anesthetize the length of the saphenous vein during endovenous procedures

Typical formulationCommon formula: 450 ml normal saline + 50 ml 1% lidocaine with epinephrine (1:100,000) and 10 ml sodium bicarbonate

PurposeCollapses the vein onto the catheter, dissipates heat, and provides extensive local anesthesia

Radiofrequency ablation (RFA)

DefinitionEndoluminal thermal ablation using a radiofrequency catheter to heat the vein lumen (to about 85°C), producing scarring and closure of the treated vein

Procedure timeAverage treatment time in office setting ≈ 20 minutes

Post-procedure careCompression stockings/bandages applied to reduce VTE risk and postoperative bruising/tenderness

Endovenous laser ablation (ELAS/EVLA)

DefinitionCatheter-based laser therapy where laser energy is applied via an intraluminal fiber to collapse and seal the saphenous vein under ultrasound guidance

Anatomic requirementCatheter requires saphenous vein minimum diameter of 4.5 mm to be used

MechanismThermal energy produces endothelial and vein wall damage leading to occlusion and abolishing reflux

CAE/CAPE (cyanoacrylate embolization)

DefinitionEndovenous use of cyanoacrylate tissue adhesive (e.g., VenaSeal, VariClose) to occlude incompetent truncal veins without thermal energy or tumescent anesthesia

Clinical contextNon‑thermal, non‑tumescent glue used for GSV and SSV incompetence in multiple trials and series

Operational advantageOften does not require tumescent anesthesia and may have shorter procedure times and less peri-procedural pain

Endothermal ablation (EVLA/RFA/ETA)

DefinitionEndothermal ablation (EVLA/RFA/ETA): thermal energy applied endovenously to close refluxing truncal veins, typically requires tumescent anesthesia

ModalitiesIncludes endovenous laser ablation (EVLA) and radiofrequency ablation (RFA)

Common goalsAblate the refluxing vein segment to abolish reflux and improve symptoms and QOL

Foam sclerotherapy (UGFS)

DefinitionUltrasound‑guided foam sclerotherapy (UGFS): injection of sclerosant foam to occlude varicose veins

Effectiveness noteRCTs show variable technical success and potentially higher recurrence compared with thermal methods

Safety considerationsCommon AEs include retained coagulum, leg pain, and superficial thrombophlebitis; pulmonary emboli were not detected in cited RCTs

CAC/NBCA

DefinitionCAC/NBCA: N‑butyl cyanoacrylate (NBCA) or cyanoacrylate adhesive used endovenously to seal and fibrose incompetent truncal veins

ExamplesCommercial systems include VenaSeal and VariClose

OutcomeReported high short- and mid-term occlusion rates (eg, 90%+ in many series)

CAC/NBCA

DefinitionN‑butyl cyanoacrylate (NBCA) or cyanoacrylate adhesive closure (CAC): non‑thermal, non‑tumescent endovenous glue ablation technique

Comparative findingsMeta-analyses and RCT data suggest CAC may have similar or better early anatomical failure rates versus RFA/EVLA

Typical follow-up outcomeOcclusion rates at 24–36 months reported around 94–95% in RCTs/series

Anatomic success definition example

Example definitionAnatomic success: complete closure of the treated vein within 6 months after intervention (used as primary outcome in network meta-analysis)

Use in evidence synthesisAnatomic success used to compare modalities across RCTs in network meta-analyses

Alternate study-specific definitionsSome studies define AS variably (eg, re-canalized segment <10 cm counted as success in some MOCA studies)

NBCA / CAC

DefinitionNBCA / CAC: cyanoacrylate tissue adhesive used endovenously to occlude incompetent truncal veins without tumescent anesthesia

DevicesExamples include VenaSeal (Sapheon/VenaSeal Closure System) and VariClose

Clinical notesDevices have been evaluated in RCTs and observational series with serial duplex follow-up

CEAP classification

DefinitionCEAP classification: Clinical, Etiological, Anatomical, and Pathophysiological classification of venous disease, used in study eligibility (commonly C1–C6)

Use in trialsMany trials enroll CEAP C2–C6 patients to assess treatment effectiveness

Outcome reportingCEAP class used alongside VCSS and PROMs to evaluate clinical outcomes

Cyanoacrylate ablation (CAG/CAC)

DefinitionCyanoacrylate ablation (CAG/CAC): endovenous delivery of cyanoacrylate glue (eg, VenaSeal, VariClose) to seal incompetent superficial veins without thermal energy or tumescent anesthesia

Clinical advantagesMay reduce peri-procedural pain and avoid thermal nerve injury; often does not require tumescent anesthesia

EvidenceRandomized and observational studies report high short- and mid-term occlusion rates (eg, ~94–96%)

Anatomic failure / non-occlusion

DefinitionAnatomic failure / non-occlusion: incomplete stripping or non-occlusion of the great saphenous vein (GSV) with or without reflux as applied in comparative outcome studies

Outcome relevanceUsed as a primary outcome (eg, anatomical failure rates compared across modalities in network meta-analysis)

TimeframeReported at early, mid, and long-term follow-up intervals in RCTs and meta-analyses

ClariVein / MOCA

DefinitionClariVein / MOCA: mechano-chemical ablation combining mechanical endothelial injury by a rotating wire with simultaneous infusion of liquid sclerosant to produce vein fibrosis

Key characteristicsNo tumescent anesthesia required; lower peri-procedural pain and shorter procedure time reported in some series

OutcomesPooled short-term anatomical success ~92%; mid-term anatomic success may decline over years

Cyanoacrylate closure (CAC / CAE)

DefinitionCyanoacrylate closure (CAC / CAE): endovenous ablation using cyanoacrylate tissue adhesive to seal the incompetent vein without tumescent anesthesia

SystemsCommercial examples include VenaSeal and VariClose

Clinical outcomesRCTs report high occlusion rates and improvements in symptoms and QOL with low serious adverse events in short- to mid-term follow-up

Anatomical success (AS)

DefinitionAnatomical success (AS): closure of the treated vein on follow-up duplex ultrasound imaging; study definitions vary (eg, complete occlusion or re-canalized segment <10 cm)

Study-specific exampleOud et al defined AS as complete occlusion or re-canalized segment <10 cm; RF‑AS (reflux-free AS) similarly defined with reflux considerations

UseAS used as primary anatomical endpoint across RCTs, registries, and systematic reviews

MOCA (mechano-chemical ablation)

DefinitionMOCA (mechano-chemical ablation): non‑thermal technique combining mechanical endothelial damage with chemical sclerosant to close incompetent veins

Typical outcomesShort-term anatomical success rates typically ~90%+, with low major complication rates (≤0.2% nerve injury in pooled reviews)

Evidence gapsRandomized long-term comparative data limited; some studies show decline in anatomical success over time

Anatomical success (study-specific definition)

Example study-specific AS definitionComplete occlusion or a re-canalized segment <10 cm (Oud et al) — used to categorize anatomical success in long-term MOCA follow-up

Alternate metricReflux-free AS (RF-AS) defined as AS plus re-canalized segment with <10 cm of reflux

Clinical implicationHeterogeneity in AS definitions across studies affects comparability of reported durability

CAC (alternate reference)

Alternate CAC referenceVenaSeal and VariClose systems studied in RCTs and cohorts showing high short- and mid-term occlusion rates

Evidence sourcesVeClose RCT, single-center cohorts (Almeida, Tang, Eroglu) and systematic reviews/meta-analyses

Outcomes summary24-month CAC closure ~94–95% in VeClose; 36-month single-arm occlusion ~94.7% in Almeida series

ASVAL definition

DefinitionASVAL: ambulatory selective variceal ablation under local anesthesia — isolated phlebectomy targeting tributary varicosities while preserving the trunk

Clinical rationalePreserves the saphenous trunk when appropriate; may be used in selected patients to treat tributary varicosities

Outcome considerationsMay avoid trunk ablation but long-term outcomes depend on presence/absence of trunk reflux

Sclerotherapy (definition)

DefinitionSclerotherapy: endovenous chemical ablation using injected sclerosant to occlude veins

Appropriate useEffective for small-to-moderate varicosities without junctional reflux; junctional reflux should be corrected prior to sclerotherapy

LimitationsLarge varicosities (>6 mm) and junctional reflux are not suitable for standalone sclerotherapy

Phlebectomy (definition)

DefinitionPhlebectomy: outpatient procedure using small incisions (scalpel or needle) to remove varicose veins

IndicationUsed to remove surface varicosities not involving the saphenous trunk; recurrence likely if source reflux is untreated

Post-procedure careCompression and broad compression pads reduce hemorrhage and improve resorption after phlebectomy

Policy Dates and Revision History

1995-11-20effective_date

Policy became effective.

2026-08-03last_reviewLatest

Policy last reviewed.

2027-01-14next_review

Next scheduled policy review date.