Blue Cross Blue Shield MA varicose veins references

Coverage Criteria for Varicose Veins and Venous Insufficiency

Great or Small Saphenous Veins - Medically Necessary

Covered when ALL of the following are met:

Saphenous treatment criteria: There is demonstrated saphenous reflux and CEAP class C2 or greater.

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Indications: Documentation of one or more: ulceration secondary to venous stasis; recurrent superficial thrombophlebitis; hemorrhage or recurrent bleeding from a ruptured superficial varicosity; or persistent symptoms (pain, swelling, itching, burning) associated with saphenous reflux.

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Functional impact: Symptoms significantly interfere with activities of daily living.

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Conservative therapy failure: Failure after use of medical-grade compression stockings (medical grade at least 20-30 mmHg).>=20-30 mmHg

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Accessory Saphenous Veins - Medically Necessary

Covered when ALL of the following are met:

Isolated incompetence: Incompetence of the accessory saphenous vein is isolated.

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Demonstrated reflux: There is demonstrated accessory saphenous reflux.

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Functional impact: Symptoms significantly interfere with activities of daily living.

Perforator Veins - Medically Necessary for Leg Ulcers

Covered when ALL of the following are met:

Demonstrated perforator reflux: There is demonstrated perforator reflux.

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Prior elimination of superficial veins: Superficial saphenous veins and symptomatic varicose tributaries have been previously eliminated.

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Ulcer persistence: Ulcers have not resolved following combined superficial vein treatment and compression therapy for at least 3 months.>=3 months

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Not secondary to DVT:

Symptomatic Varicose Tributaries - Medically Necessary (as component)

Covered when ALL of the following are met or when performed at same time or after prior treatment of saphenous veins:

Allowed techniques: Stab avulsion; Hook phlebectomy; Sclerotherapy; Transilluminated powered phlebectomy are considered medically necessary as components of treatment.

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Modality-specific coverage conclusions

Coverage stance summarized by treatment modality based on the evidence presented:

Thermal ablation (RFA, laser): Evidence from randomized controlled trials and systematic reviews shows endovenous thermal ablation of saphenous veins has similar clinical outcomes to ligation and stripping with sufficient evidence of net health benefit.RCTs and systematic reviews; 2-5 year follow-up

sufficient evidence

Microfoam sclerotherapy (FDA-approved microfoam): RCTs and systematic reviews indicate FDA-approved microfoam sclerotherapy has occlusion and recurrence rates comparable to thermal ablation or stripping and is associated with improved net health outcome.Cochrane and trials up to 5+ years

sufficient evidence

Mechanochemical ablation (MOCA): RCTs (6 months–2 years) show lower anatomic occlusion rates compared with thermal ablation and cohort data suggest possible later recanalization; evidence is insufficient to determine improvement in net health outcome.

Symptomatic Varicose Tributaries — Covered When ALL Met

Covered when ALL of the following are met

tributary_coverage: Saphenous reflux is not present or has been successfully eliminated.

based on May 2024 medically necessary statement

diameter_threshold: Veins are greater than 4 mm in diameter.> 4 mm

May 2024 policy revision

conservative_trial: Individual remains symptomatic after a six-week trial of conservative therapy (eg, medical-grade compression at least 20-30 mmHg).6 weeks

May 2024 policy revision

Saphenous Veins — Cryoablation

Coverage stance based on evidence

cryoablation_evidence: Cryoablation for saphenous vein reflux has randomized controlled trial evidence indicating inferiority to conventional stripping; evidence is insufficient to demonstrate improvement in net health outcome.

Not supported as preferred therapy per document

Perforator Veins — When Treatment is Covered

Covered in specific circumstances

perforator_failure_context: Routine ligation/ablation of incompetent perforator veins is not necessary during superficial vein procedures; however, when combined superficial vein procedures and compression therapy have failed to improve symptoms (eg, venous ulcers), treatment of perforator vein reflux may be as beneficial as alternatives.

SEPS possibly as effective as Linton with fewer adverse events; endovenous ablation may decrease morbidity (chunks 38,6)

Treatment of telangiectasia (spider veins), angiomata, and hemangiomata is classified as cosmetic and investigational. Techniques and conditions not explicitly listed as medically necessary in this policy are considered investigational; examples include non-microfoam sclerotherapy of truncal veins, sclerotherapy of perforator veins, isolated tributary sclerotherapy without concurrent or prior saphenous treatment, mechanochemical ablation, and endovenous cryoablation.

Injection(s) of sclerosant for spider veins (CPT 36468) is explicitly designated not medically necessary for Commercial Members (Managed Care, PPO, Indemnity) and may be denied when submitted for these members.

Mechanochemical ablation codes CPT 36473 and 36474 (MOCA) are considered investigational for Commercial Members (Managed Care, PPO, Indemnity). Additionally, CPT 0524T (endovenous catheter-directed chemical ablation with balloon isolation) is considered investigational for Commercial and Medicare HMO/PPO members; claims for these codes may be denied.

Cryoablation for saphenous vein reflux is supported by randomized controlled trial data that indicate inferiority to conventional stripping. Overall, the evidence is insufficient to determine an improvement in net health outcome, and cryoablation is considered investigational for treatment of saphenous veins.

Procedures that do not meet the policy’s specified medical necessity criteria are considered either cosmetic or investigational and therefore not medically necessary. Examples include treatment of telangiectasia when not meeting indications, non‑microfoam sclerotherapy of truncal veins, sclerotherapy of perforator veins, and isolated tributary sclerotherapy performed without prior or concurrent appropriate saphenous treatment.

Injection(s) of sclerosant for spider veins (CPT 36468) is explicitly listed as not medically necessary for Commercial Members (Managed Care, PPO, Indemnity) and is excluded from coverage for those products.

Use of cryoablation (cryo stripping/cryostripping) for saphenous vein reflux is considered investigational/insufficient based on randomized trial evidence showing inferiority to conventional stripping; therefore cryoablation is not supported as a covered alternative to established therapies.

A set of covered CPT codes for treatment of varicose veins and venous insufficiency is listed in the coding section of this policy (including endovenous ablation, microfoam sclerotherapy, and surgical codes). Refer to the detailed coding table in the CODING section for the complete list of covered CPT and HCPCS codes.

Coding and Code-Based Guidance

Covered CPT CodesCPTCovered

36465	Injection of non-compounded foam sclerosant with ultrasound compression maneuvers; single incompetent extremity truncal vein
36466	Injection of non-compounded foam sclerosant with ultrasound compression maneuvers; multiple incompetent truncal veins, same leg
36470	Injection of sclerosant; single incompetent vein (other than telangiectasia)
36471	Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg
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
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; subsequent vein(s) treated in a single extremity
36482	Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate); first vein treated
36483	Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate); subsequent vein(s) treated in a single extremity

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HCPCS CodesHCPCSCovered

S2202

Echosclerotherapy

ICD-10-PCS Procedure CodesICD-10

065M3ZZ	Destruction of Right Femoral Vein, Percutaneous Approach
065M4ZZ	Destruction of Right Femoral Vein, Percutaneous Endoscopic Approach
065N3ZZ	Destruction of Left Femoral Vein, Percutaneous Approach
065N4ZZ	Destruction of Left Femoral Vein, Percutaneous Endoscopic Approach
065P3ZZ	Destruction of Right Saphenous Vein, Percutaneous Approach
065P4ZZ	Destruction of Right Saphenous Vein, Percutaneous Endoscopic Approach
065Q3ZZ	Destruction of Left Saphenous Vein, Percutaneous Approach
065Q4ZZ	Destruction of Left Saphenous Vein, Percutaneous Endoscopic Approach
065T3ZZ	Destruction of Right Foot Vein, Percutaneous Approach
065T4ZZ	Destruction of Right Foot Vein, Percutaneous Endoscopic Approach

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ICD-10-PCS Procedure CodesICD-10

06BN4ZZ	Excision of Left Femoral Vein, Percutaneous Endoscopic Approach
06BP0ZZ	Excision of Right Saphenous Vein, Open Approach
06BP3ZZ	Excision of Right Saphenous Vein, Percutaneous Approach
06BP4ZX	Excision of Right Saphenous Vein, Percutaneous Endoscopic Approach
06BQ0ZZ	Excision of Left Saphenous Vein, Open Approach
06BQ3ZZ	Excision of Left Saphenous Vein, Percutaneous Approach
06BQ4ZZ	Excision of Left Saphenous Vein, Percutaneous Endoscopic Approach
06BT0ZZ	Excision of Right Foot Vein, Open Approach
06BT3ZZ	Excision of Right Foot Vein, Percutaneous Approach
06BT4ZZ	Excision of Right Foot Vein, Percutaneous Endoscopic Approach

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Not Medically Necessary CPT CodeCPTNot Covered

36468

Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk

Investigational CPT Codes (MOCA)CPTExperimental

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 in a single extremity

Investigational CPT Code (chemical ablation)CPTExperimental

0524T

Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or percutaneous, including all vascular access, catheter manipulation, diagnostic imaging, imaging guidance and monitoring

Historical/clarified coding entriesHCPCS

S2202

HCPCS code S2202 added previously (historical reference)

Device approvals citedmixed

PMA P140018

VenaSeal Closure System (FDA PMA identifier)

inv-25: Compression stocking pressure — minimum medical-grade compression pressure required for failure trial

Minimum compression pressureMedical-grade compression stockings with at least 20–30 mmHg pressure are required before procedures are considered medically necessary

PurposeDocumented failure of conservative therapy (compression) is required as part of saphenous vein treatment criteria

Reference policy statement"A failure after the use of medical grade compression stockings (medical grade at least 20-30mmHg pressure)."

inv-26: tributary vein diameter — threshold for tributary vein treatment (diameter > 4 mm)

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for inpatient services for all products and for outpatient services for Commercial Managed Care (HMO and POS) and Commercial PPO products. Providers must submit prior authorization requests using the Treatment of Varicose Veins/Venous Insufficiency Prior Authorization Request Form (MP #129) or via Authorization Manager. Lack of prior authorization when required may result in denial of payment.

Prior Authorization Request Form MP #129 must be completed and faxed: Medical and Surgical: 1-888-282-0780; Medicare Advantage: 1-800-447-2994.
Authorization Manager is available 24/7 for submission of initial authorization requests, clinical documentation, checking case status, and viewing decision letters. Enter facility NPI/provider ID and servicing surgeon NPI/provider ID when submitting.
Prior authorization required: Inpatient (all products). Outpatient: Commercial Managed Care (HMO and POS) and Commercial PPO.

Background and Clinical Context

Varicose veins and chronic venous insufficiency may be managed with surgical ligation/stripping, endovenous thermal ablation (radiofrequency or laser), microfoam sclerotherapy, or cyanoacrylate adhesive when anatomic reflux and symptomatic disease are documented. Treatment choice depends on anatomic location (great, small, accessory saphenous; tributaries; perforators) and prior treatments. Procedures require documentation of demonstrated reflux, CEAP class C2 or greater for saphenous interventions, relevant clinical indications (ulceration, recurrent thrombophlebitis, hemorrhage, or persistent symptoms affecting activities of daily living), and failure of conservative therapy such as a trial of medical‑grade compression stockings (medical grade at least 20–30 mmHg).

Definitions and Clinical Terms

inv-45: CEAP class C2 or greater — clinical classification requirement for saphenous vein procedures

Clinical thresholdCEAP class C2 or greater required for saphenous vein interventions

MeaningIndicates visible varicose veins or more severe manifestations of venous disease

DocumentationCEAP classification must be demonstrated in clinical documentation supporting treatment

inv-46: Accessory saphenous vein discharge to common femoral vein — anatomic note where concurrent treatment may be considered

Anatomic conditionAccessory saphenous vein that discharges directly into the common femoral vein

ImplicationConcurrent treatment of accessory and great/small saphenous veins may be considered medically necessary when criteria are met for each vein and anatomy documents this drainage