Colorado Rocky Mountain Health Plans venous procedures Coverage | OpenPayer
ModifiedColorado Rocky Mountain Health PlansPolicy CS117.AB
Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins
This policy governs coverage and medical necessity criteria for surgical and ablative treatments of venous insufficiency and varicose veins (including thermal and non‑thermal endovenous ablation, sclerotherapy, ligation/stripping, phlebectomy, and related procedures) for Colorado Rocky Mountain Health Plans members; it excludes certain listed states where separate state-specific policies apply.
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicySurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins
Policy CodePolicy CS117.AB
Change TypeClinical, coding, and administrative revisions (includes material clinical changes)
Effective DateAugust 1, 2025
Next Review DateN/A
Key ActionInclude duplex ultrasound reports (standing or reverse Trendelenburg) documenting vein diameter and reflux duration and prior conservative management when submitting prior authorization to support medical necessity.
Coverage rationale was revised to change which procedures are described as proven/medically necessary and to add non-thermal (cyanoacrylate-based adhesive) and foam sclerotherapy as considered reconstructive and medically necessary for GSV, SSV, and accessory veins when criteria are met.
Ablation of incompetent perforator veins using endovenous foam sclerotherapy and/or cyanoacrylate-based adhesive was added as unproven and not medically necessary due to insufficient evidence.
Coding updates: removed CPT 37500 and 37799; clarified use of CPT 36465/36466 per AMA guidance for truncal foam sclerotherapy; removed notation for CPT 37241; limited covered sclerosurgery codes to 36470 and 36471 for non-truncal non-telangiectasia up to three sessions per leg per year.
Removed content/language pertaining to the state of Louisiana.
Added language to indicate this Medical Policy does not apply to the state of Nebraska; refer to the state-specific policy version.
Added definitions for Superficial Vein, Telangiectasias/Spider Veins, and Tributary Vein; removed definitions for Cosmetic Procedures and Reconstructive Procedures.
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>=3 mmGSV/SSV minimum diameter
>=500 msReflux duration threshold
3.5 mmPerforator diameter threshold
Up to 3/leg/yrSclerotherapy session limit
states updatedState-specific updates
94–97%Typical CAC/PEM closure rates
Medical Necessity and Coverage Criteria
Thermal and Non‑Thermal Treatments — GSV/SSV/Accessory Veins
Covered when ALL of the following are met
Primary coverage criteria for ablation/stripping: Individual must have one of the listed Functional or Physical Impairments (skin ulceration; frank bleeding from a varicose vein; documented superficial thrombophlebitis; venous stasis dermatitis causing functional or physical impairment; or moderate to severe pain causing functional or physical impairment) AND target vein diameter (GSV/SSV/accessory) >= 3 mm when measured at the proximal thigh or appropriate junction AND a duplex ultrasound study performed in the standing or reverse Trendelenburg position demonstrates reflux >= 500 mssee text
Duplex interpretations describing 'moderate to severe reflux' are acceptable
Incompetent Perforator Vein Ablation
Covered when ALL of the following are met
Perforator vein ablation criteria: Evidence of perforator venous insufficiency on a recent duplex ultrasound study performed in the standing or reverse Trendelenburg position AND perforator vein size >= 3.5 mm AND perforator reflux >= 500 ms AND the perforator lies beneath a healed or active venous stasis ulcer AND the findings are not secondary to acute deep vein thrombosissee text
Ablation of perforator veins using endovenous foam sclerotherapy and/or cyanoacrylate-based adhesive is considered unproven and not medically necessary
Ligation — specific covered and not covered uses
Ligation at the saphenofemoral junction as a stand-alone procedure is proven and medically necessary when used to prevent propagation of an active clot to the deep venous system in individuals with ascending superficial thrombophlebitis who fail or are intolerant of anticoagulation; other ligation procedures of the GSV, SSV, or accessory veins as stand-alone treatments for venous reflux are unproven and not medically necessary
Ligation at the saphenofemoral junction as an adjunct to ablation is considered unproven and not medically necessary
Ambulatory Phlebectomy
Phlebectomy: Ambulatory phlebectomy is medically necessary in certain circumstances; for specific medical necessity clinical coverage criteria, refer to the InterQual® Procedures, Phlebectomy, Lower Extremity Superficial Tributary Varicose Veinsee InterQual
InterQual criteria govern the detailed clinical indications
Sclerotherapy
Sclerotherapy: Refer to Applicable Codes for sclerotherapy types. CPT 36470 and 36471 (sclerotherapy for non-telangiectasia, non-truncal veins) are covered up to three sessions per leg in a rolling 12-month period. CPT 36468 (sclerotherapy for telangiectasia/spider veins) is considered cosmetic and not medically necessary.Up to 3 sessions/leg/12 months for CPT 36470/36471
A session is one date of service; more than three sessions per leg per 12 months is considered cosmetic
Unproven / Not Medically Necessary
Unproven procedures: Endovenous mechanochemical ablation (MOCA) of varicose veins, porcine bioprosthetic valve implantation (e.g., VenoValve) for deep vein reflux, ligation of GSV/SSV/accessory veins as stand-alone procedures (except saphenofemoral ligation for propagation of clot as specified), and use of endovenous foam sclerotherapy or cyanoacrylate-based adhesive for isolated perforator veins are considered unproven and not medically necessary due to insufficient evidence of efficacy
MOCA (CPT 36473/36474) may be listed in coding but is considered unproven by policy
Trial-based eligibility
Representative inclusion criteria used in key trials (may inform coverage when adopted):
Key trial inclusion criteria: All of the following: symptomatic GSV incompetence with CEAP class C2–C5; duplex ultrasound–confirmed GSV reflux duration >= 0.5 seconds; target vein anatomy and diameter suitable for the planned procedure; and absence of trial exclusion criteria (for example, prior treatment of the target GSV in some trials)
Derived from pivotal trials such as VeClose and Alhewy et al.
Comparative efficacy/safety summary
Summary of comparative findings from systematic reviews and RCTs:
Comparative outcomes: Multiple RCTs and systematic reviews report similar anatomic closure rates and comparable improvements in symptoms and quality of life for cyanoacrylate adhesive (CAE/NBCA) versus RFA/EVLA through 24–36 months; CAE/NBCA tends to have lower periprocedural pain, less skin pigmentation and nerve injury, shorter procedure time, and may avoid tumescent anesthesia. Evidence for PEM (Varithena) shows no statistically significant difference from EVTA for vein closure in pooled analyses. MOCA shows lower one‑year occlusion rates than EVTA in some meta-analyses but mixed longer-term data.
Evidence sources include VeClose, Amshar et al., Dimech & Cassar, and multiple meta-analyses
Covered when clinically indicated for truncal vein reflux
Evidence supports use when ALL of the following are met
Primary criteria: Patient has symptomatic truncal vein reflux (GSV, SSV, or accessory saphenous vein) documented by duplex ultrasound and correlating clinical symptoms or signsduplex-confirmed reflux
Supported by multiple RCTs and cohort studies reporting high closure rates for CAE and comparable outcomes for PEM versus EVTA
Treatment selection: Choice of CAE or PEM as nonthermal/foam options is acceptable when patient-specific factors favor nonthermal approaches (for example, avoidance of tumescent anesthesia) and when clinical justification is documentedclinical justification on record
Long-term comparative data vs thermal ablation are limited; document rationale
Follow-up and outcomes: Post-procedure duplex ultrasound and symptom/quality-of-life assessments at standard intervals (eg, day 3, 1 month, 3 months, then periodic visits up to available long-term follow-up) should be documented to support outcomes and any further interventions
Limited or not supported indications (perforator veins)
Not sufficiently supported / should be limited
Perforator vein treatment: Endovascular embolization with cyanoacrylate-based adhesive or endovenous foam sclerotherapy for isolated incompetent perforator veins has limited and low-quality evidence and is not supported as routine therapy without strong clinical justification or enrollment in researchlack of robust RCT evidence
Future robust RCTs and long-term outcomes are warranted
Evidence-based guidance and limits
Guidance and evidence summarized from systematic reviews and professional society guidelines:
First-line treatment preference: For patients with GSV or SSV incompetence, endovenous thermal ablation (EVLA or RFA) is recommended as first-choice treatment in most patients; ultrasound-guided foam sclerotherapy may be considered for trunks <6 mm or when EVTA is unsuitable
ESVS and other guideline summaries support this preference
Non-thermal options: Non-thermal techniques (MOCA, cyanoacrylate adhesive) may be considered when non-thermal approach is preferred or thermal options are unsuitable; evidence shows similar QOL and less peri-procedural pain for some non-thermal methods but variable occlusion rates for MOCA
NICE and multiple meta-analyses described; MOCA may have lower occlusion vs EVTA in some analyses
Perforator vein treatment guidance: Evidence for endovenous foam sclerotherapy or other techniques for incompetent perforator veins is limited; RFA may be more reliable than UGFS for perforator closure in some studies. Consider endovenous ablation, division, or ligation for pathologic perforators especially when directed to ulcer bed
Guideline-based treatment recommendations
Recommendations from SVS/AVF/AVLS/SIR guidelines and AUC — treatments considered based on symptoms, CEAP class, reflux anatomy, and available expertise.
General diagnostic prerequisite: Duplex ultrasound is the diagnostic test of choice for evaluation of venous reflux; reflux defined as > 500 ms; use CEAP classification to document clinical severityreflux > 500 ms
Level 1 recommendation in guideline statements
Recommended treatments for symptomatic varicosities/tributaries: For symptomatic telangiectasias and reticular veins: sclerotherapy (liquid or foam) is recommended; for symptomatic varicose tributaries: miniphlebectomy or ultrasound-guided sclerotherapy (PCF/PEM) recommended; for symptomatic reflux in GSV/SSV with varicosities: ablation of refluxing trunk plus phlebectomy or UGFS (PCF/PEM) recommendedCEAP symptomatic
Grade 1–2 recommendations per guideline summaries
Ablation modality selection:
Revised medical necessity criteria (high level)
Coverage criteria and thresholds revised to apply to GSV, SSV, Accessory veins, and perforator veins as specified
Reflux threshold: Duplex ultrasound study performed in the standing or reverse Trendelenburg position showing duration of reflux >= 500 ms for the GSV, SSV, or Accessory Veins>= 500 ms
Language revised to explicitly include Accessory Veins
Perforator vein criteria: Incompetent perforator veins considered for ablation must have evidence of perforator venous insufficiency on a recent duplex ultrasound study performed in the standing or reverse Trendelenburg position, perforator vein reflux >= 500 ms, and not be secondary to acute deep vein thrombosis>= 500 ms
Added requirement: not secondary to acute DVT
Treatment modalities considered reconstructive and medically necessary: Initial and subsequent treatment of the GSV, SSV, and Accessory Veins with radiofrequency ablation, endovenous laser ablation, stripping with ligation and excision, endovenous foam sclerotherapy, and/or cyanoacrylate-based adhesive are considered reconstructive and medically necessary when all listed clinical criteria are met
Cosmetic sclerotherapy directed at spider veins/telangiectasias (CPT 36468) is considered cosmetic and excluded. For non-telangiectasia sclerotherapy (CPT 36470/36471), coverage is limited to up to 3 sessions per leg in a rolling 12-month period; more than three sessions per leg within a year is considered cosmetic and excluded. A session is defined as one date of service in which CPT 36470 or 36471 is performed, and the 12-month period is defined as a rolling 365 days.
Endovenous mechanochemical ablation (MOCA; e.g., ClariVein) is listed as unproven and not medically necessary due to limited high-quality comparative evidence. Porcine bioprosthetic venous valve implantation (e.g., VenoValve) is also designated unproven and not medically necessary pending larger trials and regulatory (FDA) approval.
Treatment of spider veins/telangiectasias is considered cosmetic and excluded from coverage. CPT 36468 (sclerosis of telangiectasias/spider veins) is considered cosmetic and not medically necessary. Endovenous ablation of reticular or telangiectatic veins is not reconstructive and is excluded from coverage.
Key randomized trials exclude certain patient groups; these trial-based exclusion criteria can inform coverage decisions. Examples include prior treatment of the target saphenous vein, reflux limited to small saphenous or anterior accessory GSV in some studies, symptomatic peripheral arterial disease, history of DVT/PE, target vein aneurysm >12 mm, BMI >35, active hypercoagulable disorder, current anticoagulant use, sensitivity to cyanoacrylate adhesives, and CEAP class 6.
Isolated treatment of incompetent perforator veins using cyanoacrylate-based adhesive (CAE/CAC) or endovenous foam sclerotherapy is not supported by robust, high-quality evidence. The policy states that ablation of incompetent perforator veins with CAE or foam is unproven and not medically necessary due to limited peer-reviewed data and recommends that such isolated perforator-only interventions be considered investigational or limited pending RCT evidence.
The VenoValve porcine bioprosthetic venous valve remains investigational and not FDA-approved. Published clinical experience is limited (early small first-in-human series), and larger randomized trials and regulatory approval are needed before routine coverage can be considered.
Guidance from vascular society recommendations advises against routine, concomitant treatment of incompetent perforating veins at the time of initial saphenous trunk ablation in patients with CEAP C2 who have significant axial GSV/SSV reflux. Treatment of pathologic perforators is generally reserved for symptomatic residual or recurrent varicosities or for ulcer‑related disease where perforator reflux is directed toward the ulcer bed.
Endovascular embolization of varicose veins using cyanoacrylate-based adhesive is addressed in the evidence review; parts of the policy history previously designated CAE as unproven/not medically necessary for some uses. Current policy identifies specific indications where CAE is reconstructive and may be medically necessary, but other uses—particularly novel or off‑label applications—remain unproven/not medically necessary and may require trial enrollment or strong justification.
Ligation of the GSV, SSV, or accessory veins as a stand‑alone procedure is generally described as unproven and not medically necessary, with an important exception: ligation at the saphenofemoral junction is considered proven and medically necessary when used to prevent propagation of an active clot to the deep venous system in individuals with ascending superficial thrombophlebitis who fail or are intolerant of anticoagulation.
Endovenous ablation of reticular veins or telangiectatic veins is stated as not medically necessary. Procedures directed at reticular or telangiectatic veins are not considered reconstructive and therefore are excluded from coverage.
Devices or systems that are not FDA‑approved (for example, the VariClose Vein Sealing System) are considered investigational in this policy segment. Such devices lack FDA clearance or approval and therefore are treated as investigational/not medically necessary for routine coverage pending further evidence and regulatory status.
Use of cyanoacrylate adhesive or endovenous foam sclerotherapy specifically for isolated perforator‑only incompetence lacks sufficient peer‑reviewed evidence to support routine coverage. The policy notes limited small series and retrospective reports, and calls for larger randomized trials and longer‑term outcomes before considering these approaches medically necessary for isolated perforator treatment.
MOCA (mechanochemical ablation) has mixed evidence: systematic reviews and meta‑analyses report good short‑term anatomical success but some RCT meta‑analyses show lower one‑year occlusion rates compared with EVTA. Consequently, isolated MOCA for indications that require demonstrated long‑term occlusion may be considered less effective than EVTA; policy language lists MOCA as unproven/not medically necessary for some indications unless sufficient comparative evidence is provided.
The Society for Vascular Surgery guidance suggests that in symptomatic CEAP C2 patients truncal vein diameter alone should not determine the need for truncal ablation. Diameter measurements can inform planning, but treatment decisions should be based on symptoms, duplex‑documented reflux, and overall clinical assessment rather than diameter alone.
The policy restates that ablation of incompetent perforator veins using endovenous foam sclerotherapy and/or cyanoacrylate‑based adhesive is unproven and not medically necessary because current evidence is limited, comprised largely of small cohorts and retrospective studies, and lacks robust randomized controlled trial data with long‑term outcomes.
Applicable CPT/HCPCS Codes and Coding Rules
Applicable CPT/HCPCS Codesmixed
0744T
Insertion of bioprosthetic valve, open, femoral vein (e.g., VenoValve)
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
36468
Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk
36470
Injection of sclerosant; single incompetent vein (other than telangiectasia)
36471
Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg
36473
Endovenous ablation therapy, mechanochemical; first vein treated
36474
Endovenous ablation therapy, mechanochemical; subsequent vein(s) treated in a single extremity
36475
Endovenous ablation therapy, radiofrequency; first vein treated
36476
Endovenous ablation therapy, radiofrequency; subsequent vein(s) treated in a single extremity
1–10 of 22
1/3
Procedures referenced (no explicit codes listed)mixed
affected codes
Trials reference procedures such as cyanoacrylate closure (CAC), radiofrequency ablation (RFA), and endovenous laser ablation (EVLA) but do not list specific CPT/HCPCS codes in the cited text.
CAE/CAC (VenaSeal) — codes not specifiedmixed
none listed in extract
Document discusses VenaSeal/CAE clinical studies and FDA PMA (P140018); no procedural CPT/HCPCS code is specified for CAE in this section.
P140018
FDA PMA number for VenaSeal Closure System (informational)
K071468
FDA 510(k) clearance number for ClariVein infusion catheter (informational)
PEM (Varithena) — codes not specifiedmixed
none listed in extract
Document discusses Varithena (polidocanol injectable foam) clinical studies and FDA approval but does not specify procedural CPT/HCPCS codes in this section.
Varithena
Polidocanol injectable foam — FDA approved for incompetent GSVs and accessory saphenous veins (informational)
Perforator vein procedures — codes not specifiedmixed
none listed in extract
Statements on perforator vein treatments (CAE or endovenous foam sclerotherapy) are provided, but no billing codes are specified in this extract.
FDA device approvals / clearances (informational)mixed
K071468
FDA 510(k) clearance number for ClariVein infusion catheter (informational)
P140018
FDA PMA number for VenaSeal Closure System (informational)
Approved sclerosing agents (informational)mixed
Varithena
Polidocanol injectable foam (PEM) — FDA approved for incompetent GSVs, accessory saphenous veins, and visible varicosities (informational)
Asclera
Polidocanol (Asclera) — FDA-approved sclerosing agent indicated for spider veins and uncomplicated reticular veins (informational)
Sclerotherapy and related CPT codesCPT
36465
Sclerotherapy; per AMA guidance for truncal veins (injection of non-compounded foam sclerosant with ultrasound compression maneuvers)
36466
Sclerotherapy; per AMA guidance for truncal veins (multiple truncal veins, same leg)
36468
Sclerotherapy treatment for spider veins/telangiectasias (considered cosmetic)
36470
Sclerotherapy; non-truncal, non-telangiectasia (covered up to three sessions per leg/year)
36471
Sclerotherapy; non-truncal, non-telangiectasia (covered up to three sessions per leg/year)
Removed CPT codesCPTNot Covered
37500
Removed from applicable codes list
37799
Removed from applicable codes list
Duplex ultrasound thresholds and vein diameter requirements (GSV/SSV/accessory)
Target veinsGreat Saphenous Vein (GSV), Small Saphenous Vein (SSV), and Accessory veins must measure ≥ 3.0 mm in diameter when measured at the proximal thigh or immediately below the appropriate junction on duplex ultrasound
Reflux duration thresholdDuplex ultrasound performed standing or in reverse Trendelenburg demonstrates reflux ≥ 500 milliseconds (ms)
Acceptable duplex wordingDuplex interpretations describing 'moderate to severe reflux' are acceptable equivalently to numeric ≥ 500 ms
Sclerotherapy session limit
Prior Authorization, Documentation, and Operational Requirements
Prior Authorization
Prior Authorization Required
Prior authorization is required for procedures listed in the Applicable Codes when coverage is requested. Documentation must demonstrate medical necessity and support the requested procedure(s). Requests may be subject to review and denial if required documentation is incomplete or absent.
Prior authorization implied for procedures in Applicable Codes — submit clinical notes, duplex ultrasound report, and CEAP classification.
Medical records documentation may be required to assess eligibility; absence may result in PA denial.
Denial Risk
Coverage Exclusions — Cosmetic Procedures
Certain procedures are excluded from coverage as cosmetic or not medically necessary. Prior authorization requests for these services should be denied or not accepted.
Sclerotherapy for spider veins/telangiectasias (CPT 36468) is considered cosmetic and excluded.
Key Terms and Definitions
Varicose veins result from venous reflux when incompetent venous valves allow blood pooling in superficial veins, producing dilated tributaries often >3 mm in diameter. Clinical consequences include aching, heaviness, venous stasis dermatitis, superficial thrombophlebitis, bleeding, and venous leg ulcers. Duplex ultrasonography (standing or reverse Trendelenburg) is the diagnostic standard to document reflux and guide treatment decisions.
Duplex Ultrasonography — noninvasive imaging description and usage
Modality descriptionDuplex ultrasonography: noninvasive imaging combining B-mode with Doppler to assess blood flow and reflux in leg veins
Patient positioningPerformed standing or in reverse Trendelenburg to measure reflux accurately
Use casesPreoperative evaluation for venous insufficiency, mapping anatomy, measuring vein diameters, and documenting reflux duration for coverage decisions
Venous Reflux/Insufficiency thresholds
Evidence Highlights and Key Metrics
>=3 mmVein diameter threshold (GSV/SSV/Accessory)
>=500 msDuplex reflux duration threshold for truncal veins
3.5 mmPerforator vein diameter threshold
Up to 3Covered sclerotherapy sessions per leg / 12 months (36470/36471)
Varicose veins develop from valvular incompetence in superficial venous systems leading to symptomatic dilated veins and potential complications such as skin changes, thrombosis, bleeding, and ulceration. Duplex ultrasound performed in the standing or reverse Trendelenburg position is used to assess vein diameter and reflux duration, and CEAP clinical classification is used to grade disease severity and guide management.
Policy Update Log
2026-04-01administrativeLatest
Removed content/language pertaining to the state of Louisiana.
2025-10-01administrative
Added language indicating this Medical Policy does not apply to the state of Nebraska and to refer to the state-specific policy version.
2025-08-01clinical_revision
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicySurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins
Policy CodePolicy CS117.AB
Change TypeClinical, coding, and administrative revisions (includes material clinical changes)
Effective DateAugust 1, 2025
Next Review DateN/A
Key ActionInclude duplex ultrasound reports (standing or reverse Trendelenburg) documenting vein diameter and reflux duration and prior conservative management when submitting prior authorization to support medical necessity.
VeClose and cohort studies report closure status at multiple timepoints up to 60 months
Guideline statements caution against routine concomitant treatment of perforators in CEAP C2 with axial reflux
Investigational devices: Implantable porcine bioprosthetic venous valves (VenoValve) and other novel devices are investigational with limited evidence and require trial enrollment or robust justification and follow-up plans
Small first-in-human studies and Hayes report indicate investigational status
For symptomatic varicose veins with axial reflux in GSV/SSV: endovenous ablation is preferred over high ligation and stripping when available; both thermal and nonthermal ablation are acceptable depending on expertise and patient preference; EVLA/RFA or high L&S suggested over physician-compounded UGFS when long-term outcomes are prioritized
axial reflux present
Guideline-based strength varies by modality and vein
Accessory and perforator veins: For anterior/accessory GSV or posterior accessory GSV reflux: simultaneous ablation plus phlebectomy or UGFS is suggested; routine treatment of incompetent perforators concomitant with initial saphenous ablation is generally not recommended in CEAP C2 with significant axial reflux; pathologic perforators directing flow to ulcer bed in C4–C6 may be treatedCEAP C2 or higher
Mixed strength recommendations and consensus statements
Ulcer-related recommendations: For active (C6) or healed (C5) venous leg ulcers with incompetent superficial veins and pathologic perforators (>500 ms reflux and diameter >3.5 mm) directed to the ulcer bed: ablation of incompetent superficial veins and perforators plus compression therapy is suggested to aid healing and prevent recurrenceCEAP C5–C6
Grade 1–2; level C evidence in guidelines
Appropriate Use Criteria summary: AUC rates ablation for axial GSV reflux (symptomatic CEAP C2–C6) as appropriate; treatment of perforators with high outward flow and large diameter directed toward affected area in symptomatic patients with skin/subcutaneous changes (C4–C6) is considered appropriateAUC scenarios
AUC intended as guide where high-quality evidence is lacking
Policy expanded to include non-thermal modalities when criteria are satisfied
Covered CPT codesCPT 36470 and 36471 (sclerotherapy for non-telangiectasia varicose veins)
Session limitUp to 3 sclerotherapy sessions per leg in any rolling 12‑month period for CPT 36470/36471
Excess treatment designationMore than three sessions per leg within a year is considered cosmetic and excluded from coverage
Duplex reflux duration threshold
Numeric threshold>= 0.5 seconds (>= 500 ms) reflux duration on duplex ultrasound used in key trials and inclusion criteria
Trial contextRandomized trials (eg, Alhewy et al.) required duplex-confirmed GSV reflux duration ≥ 0.5 seconds for enrollment
Measurement positionDuplex performed in standing or reverse Trendelenburg position per trial and policy requirements
Duplex reflux duration — >= 500 ms (alternate indexing)
Numeric threshold (alternate indexing)>= 500 ms duplex reflux duration (policy-stated minimum value for reversed flow)
ScopeApplies to superficial truncal and perforating veins as defined in policy guidance
Documentation requirementDuplex ultrasound reports must document reflux duration and vein diameters to support medical necessity
Pathologic perforator diameter
Diameter thresholdPerforator vein diameter ≥ 3.5 mm on duplex ultrasound
Reflux requirementPerforator vein must have reflux duration ≥ 500 ms to be considered pathologic
Clinical contextPathologic perforators meeting these thresholds are considered in the policy for ablation when associated with ulcers or appropriate indications
Duplex ultrasound reflux duration (ms notation)
Numeric notation (ms)>= 500 milliseconds (ms) duplex reflux duration for GSV, SSV, or Accessory veins per revised policy wording
Equivalent phrasingPolicy notes duplex readings may state 'greater than or equal to 500 milliseconds' or 'moderate to severe reflux' as acceptable
Measurement positionDuplex must be performed standing or in reverse Trendelenburg
Cosmetic sclerotherapy and treatments solely for spider veins/reticular veins are excluded.
Endovenous ablation of reticular or telangiectatic veins is excluded.
Documentation Required
Clinical and Imaging Documentation Required
Authorization for treatment of truncal or axial reflux requires clear documentation of clinical severity and objective duplex-confirmed reflux.
Document CEAP clinical class (C2–C6 as applicable); many trials and guidance use CEAP C2–C5.
Duplex ultrasound must document axial or truncal reflux with reflux time > 500 ms (0.5 seconds) in the relevant truncal vein(s).
Specify the affected vein(s) (GSV, SSV, AAGSV, PAGSV) and whether reflux is axial or junctional.
Prior Authorization
Authorization — Evidence and Follow-Up
Prior authorization requests should include history of conservative management, prior procedures when applicable, and planned follow-up. For technologies with shorter trial evidence (e.g., CAE), include trial-period documentation and planned imaging follow-up.
Document prior conservative treatments (compression therapy, exercise, leg elevation) and duration.
If prior interventions were performed, document dates, type, and outcomes (e.g., prior ablation, sclerotherapy, phlebectomy).
Include a plan for post-procedure duplex surveillance (examples used in trials: day 3, 1 month, 3 months, then periodic visits at 6, 12, 24, 36 months).
For CAE or other newer agents, include any trial-period results and plan for longer-term outcome assessment.
Prior Authorization
Investigational Device / Procedure — PA Note
Devices and procedures that are not FDA-approved or are considered investigational require specific investigational review and documentation; authorization may be denied pending review.
Flag devices/procedures not FDA-approved (e.g., VenoValve) on the PA request for investigational review.
Provide device name, manufacturer, study identifiers (if investigational), and available clinical evidence when requesting coverage for investigational devices.
Note
Device/Agent Documentation (Informational)
When a device-specific agent or novel technique is used, document the agent, device model, and rationale for selection in the medical record and prior authorization submission.
For cyanoacrylate, document product used (e.g., VenaSeal™) and FDA status.
For sclerosing agents, include agent name and concentration (e.g., polidocanol, sodium tetradecyl sulfate, Varithena® where applicable).
Billing Rule
Prior Authorization and Coding Guidance
Coding and session limits apply. Follow AMA and payer coding guidance when submitting requests and claims to avoid denials.
Per AMA guidance, only one primary endovenous ablation code per extremity for the initial vein (e.g., 36475) and one add-on code per extremity for subsequent veins (e.g., 36476) may be billed.
Sclerotherapy: CPT 36470 and 36471 are covered for non-truncal (non-telangiectasia) sclerotherapy up to three sessions per leg within a rolling 12-month period (365 days).
CPT 36468 (sclerosant treatment for spider veins/telangiectasias) is cosmetic and not covered.
Refer to the Applicable Codes section for the full code list and confirm payer-specific coding rules.
Denial Risk
Perforator Vein Treatment — Evidence Limitations
Requests for perforator vein treatments (endovenous embolization, foam sclerotherapy, or CAE) should be carefully evaluated; evidence is limited and may trigger additional review or denial.
Evidence for CAE or foam sclerotherapy of perforator veins is limited — provide robust documentation if requested (indication, ulcer status, prior therapies).
Treatment of perforator veins may be considered in patients with symptomatic venous ulcers or when perforators are demonstrably the source of symptoms, but the literature is limited and payer may request additional supporting data.
Denial Risk
Insufficient Evidence for Novel/Less-Established Procedures
Less-established or novel procedures (MOCA, some non-thermal techniques, VenoValve, alternative cyanoacrylate uses) have insufficient evidence for routine coverage and may be subject to denial or require investigational review.
MOCA (mechanochemical ablation) shows mixed occlusion rates versus EVTA; include outcomes data when requesting coverage and justify deviation from preferred therapies.
VenoValve and other implantable venous valves lack sufficient evidence and FDA approval; these requests should be marked investigational.
Novel uses of cyanoacrylate or combined techniques for indications not supported by RCTs may be considered unproven.
Denial Risk
Documentation-Based Denials — Common Triggers
PA denials may be issued when documentation does not meet clinical criteria or required imaging and records are missing.
Denial triggers include absence of duplex ultrasound demonstrating reflux > 500 ms, missing CEAP classification, or lack of documentation of prior conservative measures.
Requests for services described in the policy as unproven or not medically necessary (e.g., certain endovascular embolizations, investigational devices) may be denied.
Medical records documentation used for reviews may be requested and failure to provide records can lead to denial.
Step Therapy
Treatment Selection and Step-to-Established-Thermal Ablation
When alternative or non-preferred techniques are proposed, document the rationale and prior steps toward established thermal ablation.
Preferred first-line intervention for most GSV/SSV incompetence is EVTA (EVLA or RFA); document why non-thermal techniques are selected when used.
If claiming a stepwise approach, document prior standard therapies tried and why thermal ablation was not suitable or failed.
Include comparative evidence or patient-specific reasons when choosing CAC, MOCA, or foam over thermal ablation.
Prior Authorization
Preferred First-Line Interventions
EVTA (endovenous thermal ablation — EVLA/RFA) is generally the preferred first-line intervention for symptomatic truncal reflux; document reasons for deviation from this preference.
For symptomatic GSV or SSV axial reflux, EVLA or RFA is preferred due to established outcomes; if choosing an alternative, provide clinical justification.
If EVTA is not available or anatomy precludes it, document why and provide details of alternative plan (e.g., UGFS, L&S).
Pathologic reflux thresholds
Deep veins: ≥ 1.0 second; Superficial and perforator veins: ≥ 0.5 second (≥ 500 ms)
Policy applicationPolicy uses ≥ 500 ms as the threshold for superficial truncal (GSV/SSV/accessory) and perforator veins for coverage decisions
Guideline supportSVS/AVF/AVLS/SIR guidance defines reflux > 500 ms as pathological for superficial and perforator veins
CEAP C2 definition — varicose veins > 3 mm
CEAP C2 definitionVaricose veins: dilated subcutaneous tributaries ≥ 3.0 mm in diameter (clinical class C2)
Clinical classification useCEAP 'C' classification (C0–C6) used to grade disease severity and guide treatment decisions
Implication for coveragePresence of CEAP C2 or higher with symptomatic impairment supports consideration for interventions per policy criteria
DefinitionEndovenous adhesive embolization (eg, VenaSeal): cyanoacrylate-based adhesive closure of superficial truncal veins; non‑thermal, non‑sclerosant, often does not require tumescent anesthesia
Clinical evidence summaryRCTs (eg, VeClose) and systematic reviews report high GSV closure rates (eg, 94–97% at 12–36 months) with favorable safety and patient satisfaction compared with RFA
Documentation noteDevice has FDA PMA (VenaSeal) but use still requires documentation of indication and imaging per policy; prior authorization considerations apply
DefinitionPolidocanol endovenous microfoam (PEM / Varithena): proprietary low‑nitrogen 1% polidocanol microfoam sclerosant for ultrasound‑guided intravenous injection to treat venous incompetence
Trial contextRandomized and comparative studies (eg, VANISH, PEM vs EVTA meta-analyses) show PEM can improve symptoms and has closure rates not statistically different from EVTA in aggregated analyses
Coding notePolicy references AMA guidance to use CPT 36465/36466 for truncal foam injections and limits CPT 36470/36471 to non‑truncal indications up to three sessions/leg/year
Mechanochemical ablation (ClariVein) definition
DefinitionMechanochemical ablation (MOCA, e.g., ClariVein): catheter with rotating wire causing mechanical endothelial disruption combined with sclerosant infusion to induce sclerosis and occlusion
Intended use and evidenceDesigned as a non‑thermal alternative for saphenous vein ablation; systematic reviews show good short‑term anatomical success (≈87–92%) but some RCT meta-analyses report lower occlusion rates vs EVTA
Policy stanceMOCA is listed among procedures with limited or mixed evidence and may be considered unproven/not medically necessary for some indications per policy
CAC / NBCA definition and context
DefinitionCyanoacrylate adhesive closure (CAC / NBCA): endovascular embolization using cyanoacrylate‑based adhesives (eg, VenaSeal or other NBCA systems) to occlude target saphenous veins
ContextSystematic reviews and cohort data show high closure/occlusion rates and favorable safety profiles; comparative RCTs (VeClose) indicate similar outcomes vs RFA through 24–36 months
Evidence limitationsSome reviews include non‑FDA products and heterogeneous study designs; long‑term data beyond 36–60 months are limited in scale
CAC / CAE / VenaSeal — definition and short evidence summary
DefinitionCAC/CAE (VenaSeal): cyanoacrylate adhesive endovenous closure system for saphenous and accessory veins
Evidence summaryVeClose trial and pooled analyses report high closure rates (eg, ~94–97% at 12–36 months) with reduced need for tumescent anesthesia and favorable peri‑procedural profiles
Practical noteRequires documentation of duplex‑confirmed reflux and appropriate CEAP classification for coverage consideration
PEM / Varithena definition and trial context
DefinitionPEM / Varithena: polidocanol injectable microfoam used endovenously to sclerose varicose veins
Trial/trial contextRandomized placebo‑controlled and comparative studies (eg, VANISH, King et al., Gibson et al.) demonstrate symptom and appearance improvements; network meta‑analyses show PEM comparable to EVTA for closure in pooled analyses
Evidence gapsLonger‑term comparative trials vs EVTA with larger sample sizes remain limited; policy recommends documentation of rationale and imaging when used
MOCA definition and intended use
DefinitionMOCA: mechanochemical ablation combining mechanical endothelial disruption via a rotating wire catheter and infusion of sclerosant to induce vein closure
Intended useNon‑thermal alternative to thermal ablation for saphenous veins, intended to avoid tumescent anesthesia and thermal injury
Evidence noteSystematic reviews report good short‑term pooled anatomical success but some RCT meta‑analyses show lower occlusion versus EVTA at one year
DefinitionEndovenous foam sclerotherapy (UGFS/PEM): injection of liquid or foam sclerosant into targeted veins under ultrasound guidance to cause endothelial damage and vein closure
AgentsIncludes proprietary PEM (Varithena) and physician‑compounded foam (PCF); PEM shown superior to PCF for closure in network analyses
Clinical roleUsed for truncal and tributary varicose veins per indications and coding guidance; truncal foam may be reported with CPT 36465/36466 per AMA guidance
VenoValve definition and investigational status
DefinitionVenoValve: porcine bioprosthetic venous valve surgically implanted into the femoral vein to restore valvular competence
Regulatory/statusNot FDA‑approved; investigational with only small early human studies (eg, first‑in‑human trials) and ongoing SAVVE trial
Evidence limitationPublished experience is limited (eg, ≈11 participants in early reports); larger RCTs and long‑term outcomes required
Reflux definition — minimum >500 ms reversed flow
Reflux definitionReflux defined as reversed flow duration > 500 ms (minimum value) on duplex ultrasound for superficial truncal and perforating veins
ApplicationUsed as a diagnostic cutoff to determine pathologic reflux supporting treatment decisions
Measurement techniqueMeasured on duplex ultrasound performed standing or in reverse Trendelenburg
Axial reflux definitionUninterrupted retrograde venous flow from the groin to the calf (GSV) — indicates axial reflux
Clinical relevancePresence of axial reflux supports indication for truncal ablation versus isolated tributary treatment
DocumentationDuplex ultrasound should document axial reflux when present to support coverage decisions
Pathologic perforating vein — diameter and reflux thresholds
Pathologic perforator definitionPerforator considered pathologic when diameter ≥ 3.5 mm and outward flow duration ≥ 500 ms on duplex ultrasound in CEAP C2 patients
Coverage contextPolicy requires these duplex thresholds and that perforator not be secondary to acute DVT for ablation consideration
Clinical implicationPathologic perforators directed to ulcer beds (C5–C6) may be treated when criteria met; isolated perforator‑only interventions have limited evidence
Superficial Vein definition
DefinitionSuperficial Vein: veins located above the muscular fascia
Policy noteTerm added to Definitions section in revised policy language
RelevanceDistinguishes superficial system from deep venous system for indications and coding
Telangiectasias/Spider Veins definition
DefinitionTelangiectasias/Spider Veins: dilated small superficial veins < 1.0 mm in diameter, predominantly in the lower extremities
Coverage implicationTreatment of telangiectasias/spider veins (CPT 36468) is considered cosmetic and excluded from coverage
DistinctionDifferent from varicose veins (≥ 3 mm) which may be considered CEAP C2 and eligible for reconstructive treatment when criteria met
Tributary Vein definition
DefinitionTributary Vein: small superficial veins in the legs running close to the skin within the superficial subcutaneous plane
Clinical roleSymptomatic tributaries may be treated with phlebectomy or UGFS/PEM as adjuncts to truncal ablation per guideline recommendations
Policy noteTerm added to Definitions section in revised policy language
Revised coverage rationale to expand which procedures are considered reconstructive and medically necessary to include endovenous foam sclerotherapy and cyanoacrylate-based adhesive for GSV, SSV, and accessory veins when criteria are met; added that ablation of incompetent perforator veins using endovenous foam sclerotherapy and/or cyanoacrylate-based adhesive is unproven and not medically necessary due to insufficient evidence.
2025-08-01criteria_update
Revised duplex ultrasound language and coverage thresholds to specify reflux >= 500 ms for GSV, SSV, and Accessory Veins and added requirement that perforator veins not be secondary to acute DVT; clarified perforator reflux and measurement position.
2025-08-01coding_update
Removed CPT codes 37500 and 37799; clarified use of CPT 36465/36466 per AMA guidance for truncal foam sclerotherapy; removed notation for CPT 37241; limited covered sclerotherapy codes to CPT 36470 and 36471 for non-truncal non-telangiectasia up to three sessions per leg per year.