CurrentBlue Cross Blue Shield - MassachusettsPolicy Medical Policy #238

Treatment of Varicose Veins/Venous Insufficiency

Medical necessity criteria and prior authorization instructions for surgical and endovenous treatments of varicose veins and venous insufficiency for BCBSMA members and their providers.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyTreatment of Varicose Veins/Venous Insufficiency

Policy CodePolicy Medical Policy #238

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit initial authorization requests via Authorization Manager with required clinical documentation and appropriate servicing provider and facility NPIs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MEDICALLY NECESSARYgreat/small saphenous

MEDICALLY NECESSARYaccessory saphenous

MEDICALLY NECESSARYvaricose tributaries

>= 3 monthsperforator – ulcer threshold

Coverage Criteria for Varicose Veins and Venous Insufficiency

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Great or Small Saphenous Veins

Covered when ALL of the following are met for great or small saphenous veins:

Great/Small Saphenous Vein Criteria: There is demonstrated saphenous reflux and CEAP (Clinical, Etiology, Anatomy, Pathophysiology).

All conditions must be met

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

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

Conservative Therapy: Failure after use of medical grade compression stockings (medical grade at least 20-30 mmHg).medical grade at least 20-30 mmHg

Accessory Saphenous Veins

Covered when ALL of the following are met for accessory saphenous veins:

Isolation and Reflux: Incompetence of the accessory saphenous vein is isolated, and there is demonstrated accessory saphenous reflux.

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

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

Conservative Therapy: Failure after use of medical grade compression stockings (medical grade at least 20-30 mmHg).medical grade at least 20-30 mmHg

Symptomatic Varicose Tributaries

Covered treatments for symptomatic varicose tributaries when performed at same time or after saphenous vein treatment:

Varicose Tributary Treatments: Hook phlebectomy; transilluminated powered phlebectomy; sclerotherapy; or stab avulsion. These procedures are considered medically necessary as a component of treatment of symptomatic varicose tributaries when performed at the same time as, or following prior treatment (surgical, radiofrequency, or laser) of the saphenous veins; none of these techniques has been shown to be superior to another.

May be performed same time or following prior treatment of the saphenous veins.

Perforator Veins

Considered medically necessary for incompetent perforator veins when ALL of the following are met:

Perforator Vein Criteria: There is demonstrated perforator reflux.

All conditions must be documented.

Prior Elimination of Superficial Sources: Superficial saphenous veins (great, small, or accessory) and symptomatic varicose tributaries have been previously eliminated.

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

Exclusion: Venous insufficiency is not secondary to deep venous thromboembolism.

The policy excludes treatment of perforator veins when the underlying venous insufficiency is secondary to a prior deep venous thromboembolism. In other words, perforator vein interventions are not considered medically necessary if venous insufficiency is due to deep venous thromboembolism and this etiology must be documented in the clinical record.

Provider Actions, Prior Authorization, and Documentation

Documentation Required

Clinical documentation and PA form

Providers must submit clinical documentation that supports the medical necessity criteria for treatment of varicose veins/venous insufficiency with the prior authorization request. If the patient does not meet all policy criteria, submit a letter of medical necessity explaining why an exception is justified.

For in‑state providers: complete the Prior Authorization Request Form for Treatment of Varicose Veins/Venous Insufficiency (129) using Authorization Manager; include the PA form as an attachment if not using the electronically fillable form in Authorization Manager.
Copies of relevant clinical records (history, exam, duplex ultrasound demonstrating reflux, documentation of indications such as ulceration, recurrent superficial thrombophlebitis, bleeding, or persistent symptomatic disease) must be attached to support medical necessity.

Prior Authorization

Prior authorization submission — Initial authorization requests must be submitted via Authorization Manager

Initial prior authorization requests must be submitted via Authorization Manager. Enter the appropriate servicing provider (surgeon) NPI or provider ID — not the billing group — and enter the facility NPI or provider ID for the service location. Authorization Manager is available 24/7 to submit requests, upload clinical documentation, check case status, and print decision letters. When Authorization Manager is unavailable, the completed PA form and supporting documentation may be faxed to the numbers below.

Medical and Surgical fax: 1-888-282-0780
Medicare Advantage fax: 1-800-447-2994
Out‑of‑network provider requests: fax 888-973-0726

Denial Risk

Documentation requirement — Failure to submit supporting clinical documentation may lead to denial

Failure to submit copies of clinical documentation that support the medical necessity criteria with the prior authorization form may result in denial of the request. Ensure all required documentation (including evidence of prior conservative therapy such as medical‑grade compression stockings at 20–30 mmHg) is provided.

If patient does not meet criteria, include a letter of medical necessity explaining justification for exception.
Document prior failure of medical grade compression stockings (at least 20–30 mmHg) when applicable.

Background

Varicose veins and chronic venous insufficiency result from pathologic reflux in the superficial venous system (including great, small, and accessory saphenous veins) and can produce symptoms such as pain, swelling, skin changes, bleeding, thrombophlebitis, and leg ulcers. Treatment options include surgical ligation/stripping, endovenous thermal ablation, sclerotherapy, cyanoacrylate adhesive, and phlebectomy techniques. Perforator vein treatment is considered only when there is demonstrated perforator reflux and other superficial sources of reflux have been eliminated, and ulcers have failed to resolve after combined superficial vein treatment plus compression therapy for at least 3 months.

OpenPayer

Treatment of Varicose Veins/Venous Insufficiency

Coverage Criteria for Varicose Veins and Venous Insufficiency

Coding and Related Details

Provider Actions, Prior Authorization, and Documentation

Background

Definitions