CurrentCapital BluecrossPolicy MP 1.061

Treatment of Varicose Veins - Venous Insufficiency

Defines medical necessity criteria, investigational or cosmetic determinations, and coding guidance for surgical, endovenous, sclerotherapy, mechanochemical, cyanoacrylate, cryoablation, and phlebectomy treatments of varicose veins and venous insufficiency for Capital Blue Cross products (particular product variations noted). This is part 1 of 2 and includes clinical criteria, policy guidelines, background, evidence summary, definitions, regulatory status, and partial coding lists.

Policy Summary

PayerCapital Bluecross

PolicyTreatment of Varicose Veins - Venous Insufficiency

Policy CodePolicy MP 1.061

Change TypeMultiple minor and administrative revisions (2021-2026), major removals 03/26/2025

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionProviders must document demonstrated saphenous or accessory saphenous reflux and CEAP clinical class (C2 or greater) in the medical record to support medical necessity for saphenous/accessory treatments.

SourceLink

POLICY UPDATE CHANGES

03/26/2025 Minor Review removed many prior quantitative criteria (reflux and vein size) and redefined conservative management; several indications and criteria were removed or changed, and sclerotherapy for perforator veins was changed to investigational.

07/27/2023 Minor Review added CEAP class C2 classifications and specific reflux/size measures for certain vein categories and expanded reflux duplex evaluation guidance.

08/13/2021 Minor Review added vein size requirement to Great or Small Saphenous Veins and clarified hemorrhage criteria by requiring medical or surgical intervention.

12/04/2025 Administrative Update removed CPT code 37500 because it was deleted effective 01/01/2026.

02/04/2026 Consensus Review: No change to policy statement; Rationale updated; References added.

C2+

Coverage Summary

Scope: This policy (MP 1.061) defines medical necessity, investigational, and cosmetic determinations and coding guidance for treatment of varicose veins and chronic venous insufficiency for Capital Blue Cross products. It covers surgical approaches (ligation and stripping), endovenous thermal ablation (radiofrequency or laser), sclerotherapy including FDA-approved microfoam, mechanochemical ablation (MOCA), cyanoacrylate adhesive (CAC), cryoablation, and phlebectomy techniques (stab avulsion, hook phlebectomy, transilluminated powered phlebectomy/TIPP).

Coverage stance (high-level summary): mixed — several modalities are considered medically necessary when specified clinical criteria are met (for example, endovenous thermal ablation, FDA-approved microfoam sclerotherapy, cyanoacrylate adhesive, standard surgical techniques, and phlebectomy/TIPP in indicated scenarios), while other techniques are investigational or cosmetic for many indications (examples include MOCA/mechanochemical ablation for which evidence is mixed/insufficient for long-term net health benefit, endovenous cryoablation which is insufficient or inferior in trials, and many sclerotherapy techniques or uses such as sclerotherapy of perforator veins or treatment of telangiectasia which are considered investigational or cosmetic).

When medically necessary (examples summarized): surgery (ligation/stripping), thermal ablation (RFA/laser), microfoam sclerotherapy (FDA-approved microfoam), cyanoacrylate adhesive (VenaSeal and similar CAC systems), and TIPP and standard phlebectomy techniques are included as covered options when policy clinical criteria are met.

Investigational / not covered items (examples): mechanochemical ablation (MOCA) is judged to have mixed RCT results and insufficient long-term evidence for definitive net health benefit; endovenous cryoablation has RCT data indicating inferiority to conventional stripping and is considered insufficient; sclerotherapy of perforator veins and treatment of telangiectasia (spider veins) are considered investigational or cosmetic/not covered; other techniques not specifically listed are also considered investigational.

Policy-level thresholds

Demonstrated vein reflux>= 500 ms

Conservative management duration>= 3 months

CEAP clinical class requiredC2 or greater

Policy identifierMP 1.061

Clinical thresholdCEAP C2+ required

Great or Small Saphenous Veins - Criteria

Great or Small Saphenous Veins - Medically Necessary

Treatment may be considered medically necessary when ALL of the following are met:

ALL of the following

There is demonstrated saphenous reflux (defined as ≥ 500 ms).
CEAP (Clinical, Etiology, Anatomy, Pathophysiology) clinical class C2 or greater is documented.
Documentation of one or more of the following indications:
- Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity.
- Persistent symptomatic saphenous reflux

Accessory Saphenous Veins - Criteria

Accessory Saphenous Veins - Medically Necessary

Treatment may be considered medically necessary when ALL of the following are met:

ALL of the following

Incompetence of the accessory saphenous vein is isolated
There is demonstrated accessory saphenous reflux>= 500 ms
Demonstrated vein reflux defined in policy
ANY of the following
- Ulceration secondary to venous stasis

Symptomatic Varicose Tributaries - Criteria

Symptomatic Varicose Tributaries - Medically Necessary (component of treatment)

The following treatments are considered medically necessary as a component of treatment when performed either at the same time or following prior treatment of the saphenous veins:

ANY of the following

Stab avulsion
Hook phlebectomy
Sclerotherapy
Transilluminated powered phlebectomy (TIPP)

Perforator Veins - Criteria

Perforator Veins - Medically Necessary (for leg ulcers)

Surgical ligation or endovenous radiofrequency or laser ablation of incompetent perforator veins may be medically necessary when ALL of the following are met:

ALL of the following

There is demonstrated perforator reflux>= 500 ms
Demonstrated vein reflux defined in policy
The superficial saphenous veins (great, small, accessory and symptomatic varicose tributaries) have been previously eliminated
Prior elimination required
Ulcers have not resolved following combined superficial vein treatment and compression therapy for at least 3 months>= 3 months

Telangiectasia and Other Investigational Techniques

Other Techniques - Investigational

The following techniques for conditions not specifically listed are investigational:

ANY of the following

Sclerotherapy techniques other than microfoam sclerotherapy of great, small, or accessory saphenous veins
Sclerotherapy of perforator veins
Sclerotherapy of isolated tributary veins without prior or concurrent treatment of saphenous veins
Stab avulsion, hook phlebectomy, or transilluminated powered phlebectomy of perforator, great or small saphenous or accessory saphenous veins

Coding

Procedure Codes - Covered when medically necessaryCPT|HCPCSCovered

36482	Endovenous ablation, complete truncal reflux (listed among covered codes when medically necessary)
36465	Sclerosant injection mapping (covered mapping)
36466	Sclerosant injection mapping (covered mapping)
36470	Sclerotherapy related code mapped to 37718 in policy
36471	Sclerotherapy mapping
36475	Sclerotherapy mapping
36476	Sclerotherapy mapping
36478	Sclerotherapy mapping
36479	Sclerotherapy mapping
36483	Endovenous ablation additional code mapping included in covered list

1–10 of 21

1/3

Procedure Codes - Investigational / Not Covered (telangiectasia)CPT|HCPCS|mixedNot Covered

36468

Sclerotherapy of telangiectasia/spider veins (listed as investigational/not covered for telangiectasia)

Procedure Codes - Investigational (techniques not listed / ClariVein example)CPTNot Covered

36473	Sclerotherapy, percutaneous, for conditions listed as investigational (example listed)
36474	Sclerotherapy, percutaneous (additional code listed as investigational)

ICD-10-CM Diagnosis Codes - Covered indications (examples listed)ICD-10Covered

I83.011	Varicose veins of right lower extremity with ulcer of thigh
I83.012	Varicose veins of right lower extremity with ulcer of calf
I83.013	Varicose veins of right lower extremity with ulcer of ankle
I83.014	Varicose veins of right lower extremity with ulcer of heel and midfoot
I83.015	Varicose veins of right lower extremity with ulcer other part of foot
I83.018	Varicose veins of right lower extremity with ulcer other part of lower leg
I83.019	Varicose veins of right lower extremity with ulcer of unspecified site
I83.021	Varicose veins of left lower extremity with ulcer of thigh
I83.022	Varicose veins of left lower extremity with ulcer of calf
I83.023	Varicose veins of left lower extremity with ulcer of ankle

1–10 of 37

1/4

Deleted codes (administrative)CPT

37500

Deleted effective 01/01/2026 (removed from policy)

Provider Actions & Operational Notes

Documentation Required

Document demonstrated reflux and CEAP class

Document in the medical record that there is demonstrated saphenous or accessory saphenous reflux and record the patient's CEAP clinical class (C2 or greater) to support medical necessity for saphenous or accessory saphenous treatments.

Documentation Required

Document symptom impact and conservative therapy trial

For symptomatic indications, document that symptoms significantly interfere with activities of daily living and that conservative management, including compression therapy, was tried for at least the required duration without improvement.

>= 3 months

Background & Evidence Summary

Background — venous anatomy and pathophysiology: The lower-extremity venous system comprises superficial veins (great saphenous, small saphenous, and accessory saphenous veins), the deep venous system (femoral and popliteal veins), and perforator veins that connect superficial and deep systems. One-way venous valves direct blood proximally; valve incompetence at any level can produce retrograde flow (venous reflux) with pooling in superficial veins and clinical manifestations ranging from varicosities to itching, heaviness, pain, thrombophlebitis, hemorrhage, and ulceration. The CEAP classification (C0–C6) is used to characterize clinical severity.

Treatment modalities and mechanisms: Traditional surgical management includes identification of reflux by duplex/Doppler ultrasonography, control of proximal reflux (e.g., saphenofemoral or saphenopopliteal ligation), and removal of the superficial vein (stripping) with removal of tributaries by stab avulsion or sclerotherapy. Minimally invasive alternatives aim to occlude the incompetent vein: thermal ablation (radiofrequency or endovenous laser) injures the vein wall to cause retraction and fibrotic occlusion; sclerotherapy destroys endothelium via injected sclerosant (liquid or foam/microfoam) assisted by ultrasound guidance and compression; mechanochemical ablation (MOCA) combines mechanical abrasion with liquid sclerosant infusion; cyanoacrylate adhesive (CAC) polymerizes within the vein to produce immediate coaptation and subsequent fibrotic occlusion; cryoablation uses extreme cold to produce vein injury and occlusion.

Rationale for selecting modality: Modality selection is influenced by symptom severity, the specific vein type (truncal saphenous veins, accessory saphenous veins, tributaries, or perforators), and the source/location of reflux. Preprocedural duplex ultrasound to identify the point(s) of reflux and map anatomy is central to planning. Evidence summaries support endovenous thermal ablation, FDA-approved microfoam sclerotherapy, cyanoacrylate adhesive, and phlebectomy/TIPP as effective options for appropriate indications; MOCA and cryoablation have more limited or mixed evidence and are considered investigational or insufficient in some contexts. Tributary treatment (stab avulsion, hook phlebectomy, sclerotherapy, or TIPP) is commonly performed as a component of saphenous vein treatment when indicated. Perforator ablation may be considered for nonhealing venous ulcers after elimination of superficial reflux and combined conservative care; routine concurrent ablation of perforators at the time of superficial vein surgery is considered investigational.

Policy Changes and Revision History

05/29/2020Minor Review

Policy Statement updated to clarify conservative management, imaging requirements, added treatment requirements for initial superficial thrombophlebitis and CEAP criteria; symptomatic varicose tributaries section clarified.

08/13/2021Minor Review

Added vein size requirement to Great or Small Saphenous Veins and clarified hemorrhage criteria by requiring medical or surgical intervention; included reflux requirements for Perforator Veins.

07/27/2023Minor Review

Added CEAP class C2 classification and specific saphenous reflux measurements to Accessory Saphenous Vein criteria; added CEAP class C2 classification and perforator vein size to Perforator Vein criteria; expanded policy guidelines to include reflux evaluation with duplex ultrasound information.

Policy Summary

PayerCapital Bluecross

PolicyTreatment of Varicose Veins - Venous Insufficiency

Policy CodePolicy MP 1.061

Change TypeMultiple minor and administrative revisions (2021-2026), major removals 03/26/2025

Effective DateJun 1, 2026

Next Review DateN/A

SourceLink

On This Page

Great or Small Saphenous Veins - Not Medically Necessary / Cosmetic/Investigational

Treatment of great or small saphenous veins that does NOT meet the medical necessity criteria above is considered cosmetic and investigational. The following are examples of treatments considered cosmetic/investigational when the criteria for medical necessity are not met:

ANY of the following

Surgery (ligation and stripping) of the great or small saphenous veins when criteria are not met.
Endovenous thermal ablation (radiofrequency or laser) of the great or small saphenous veins when criteria are not met.
Microfoam sclerotherapy of the great or small saphenous veins when criteria are not met.
Cyanoacrylate adhesive (e.g., CAC) treatment of the great or small saphenous veins when criteria are not met.

Policy Changes and Criteria History

Effective Date: 2026-06-01. Policy Number MP 1.061. Payer: Capital BlueCross.

Demonstrated vein reflux defined as ≥ 500 ms is specified in the policy guidelines and applied to saphenous reflux criteria.

Consolidated medical necessity criteria require CEAP class C2 or greater plus documented indication(s) including hemorrhage, persistent symptoms despite ≥ 3 months conservative therapy, ulceration, or recurrent superficial thrombophlebitis.

Procedures not meeting criteria are designated cosmetic and investigational due to insufficient evidence of health outcome benefits for these indications.

Accessory Saphenous Veins - Concurrent Treatment

Concurrent treatment may be medically necessary when ALL of the following are met:

ALL of the following

Criteria are met for each vein treated (great/small and accessory)
Documentation of anatomy showing the accessory saphenous vein discharged directly into the common femoral vein
Anatomic documentation required

Accessory Saphenous Veins - Not Medically Necessary / Cosmetic/Investigational

Treatment is considered cosmetic and investigational when it does not meet the medically necessary criteria above:

ALL of the following

Any surgery, endovenous radiofrequency or laser ablation, microfoam sclerotherapy or cyanoacrylate adhesive of accessory saphenous veins that does not meet the criteria above

Documentation Required

Document prior elimination of superficial veins for perforator treatment

For perforator vein ablation to treat leg ulcers, document demonstrated perforator reflux, that the superficial saphenous veins and symptomatic tributaries have been previously eliminated, and that ulcers have not resolved after combined superficial vein treatment plus compression therapy for the required duration.

Ulcer non-resolution after combined superficial treatment + compression for >= 3 months

Billing Rule

Coding must match medical necessity

Use the listed procedure and diagnosis codes consistent with the documented medical necessity in the chart; presence of a code on the list does not itself guarantee coverage — coverage is determined by member benefit terms and medical necessity.

Procedure codes and mappings listed in provider_actions/code_groups (examples): 36482, 36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, S2202, 36468, 36473, 36474
See the policy code table for complete mappings and status

Technique	Evidence Summary
Endovenous thermal ablation
RCTs and systematic reviews show improvement; sufficient evidence for net health outcome

03/26/2025Minor Review

Major removals and redefinitions: removed criteria for reflux and vein size for great/small saphenous veins; redefined conservative management; removed initial superficial thrombophlebitis criteria; removed CEAP, prior elimination, reflux and vein size requirements for accessory saphenous veins; removed symptoms and conservative treatment requirements for symptomatic varicose tributaries; removed CEAP, reflux and vein size requirements for perforator veins; changed sclerotherapy for perforator veins from medically necessary to investigational; Policy Guidelines, Benefit Variation and Disclaimer revised.