ModifiedEmblemHealthPolicy MG.MM.SU.05rC

Varicose Vein Treatment

Clinical coverage and medical necessity criteria for procedural and nonprocedural treatments of symptomatic varicose veins and venous insufficiency for EmblemHealth members.

Policy Summary

PayerEmblemHealth

PolicyVaricose Vein Treatment

Policy CodePolicy MG.MM.SU.05rC

Change TypeCriteria revision and coverage expansion (material)

Effective Date

Next Review DateJan 23, 2026

Key ActionRequest prior authorization with pretreatment duplex documentation including accessory saphenous reflux timing when applicable.

SourceLink

POLICY UPDATE CHANGES

Added Medicaid coverage of endovenous mechanochemical ablation and subfascial endoscopic perforator vein surgery.

Changed timeframe from 6 months to 90 days for recurrent episodes of superficial thrombophlebitis and/or persistent symptoms interfering with activities of daily living.

Removed 3 month trial of conservative non-operative treatment as a prerequisite for procedures.

Removed note stipulating that there should be no thrombosis that would interfere with intraluminal procedures.

Defined prerequisite accessory saphenous reflux time as > 500 msec.

May 5, 2025Most recent documented revision

90 daysRecurrent episode timeframe (revised)

500 msecAccessory saphenous reflux prerequisite

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Coverage and Medical Necessity Criteria

General procedural medical necessity

Covered when ALL of the following are met:

Documentation prerequisites: Documented patency of the deep vein system and absence of occlusion or disease; progress-note documentation of failed conservative measures; pretreatment venous Doppler or duplex ultrasound performed for localization of sites of incompetence; other documentation as requested.

Clinical indications (at least one): At least one of: recurrent episodes of superficial thrombophlebitis and/or persistent symptoms interfering with activities of daily living for >= 90 days (symptoms may include aching, cramping, burning, itching and/or swelling during activity or after prolonged standing); a single significant hemorrhage from a ruptured superficial varicosity (especially if transfusion required); >1 episode of minor hemorrhage from a ruptured superficial varicosity; intractable ulceration or infection secondary to venous stasis.

Accessory saphenous vein treatment criteria

Accessory saphenous vein treatment is medically necessary when ALL are met:

Prior elimination and reflux threshold: Great or small saphenous veins have been previously eliminated (at least 3 months) AND there is demonstrated accessory saphenous reflux time > 500 msec.

Indications for treatment: One or more of: ulceration secondary to venous stasis that fails to respond to compressive therapy; recurrent superficial thrombophlebitis that fails to respond to compressive therapy; hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity; persistent pain, swelling, itching, burning, or other symptoms associated with saphenous reflux that significantly interfere with activities of daily living.

Key revised coverage criteria

Policy revision highlights and coverage-impacting criteria

Reflux duration prerequisite: Accessory saphenous reflux time defined as > 500 msec where specified.> 500 msec

Document reflux timing with duplex ultrasound

Recurrent episodes timeframe: Timeframe for recurrent episodes of superficial thrombophlebitis and/or persistent symptoms interfering with activities of daily living revised to 90 days.90 days

Previously 6 months

Covered procedures expanded: Added coverage of endovenous mechanochemical ablation (MOCA) and subfascial endoscopic perforator vein surgery for Medicaid members.

See revision history entry dated May 5, 2025

The policy lists procedures that are considered cosmetic and therefore not medically necessary. Examples explicitly named include injection of reticular veins, telangiectasia or visible subcuticular veins < 4 mm in size (commonly referred to as spider veins) (CPT codes: 36468 and 36469), transdermal laser therapy, and photodermal sclerosis. Sclerotherapy directed at the great saphenous vein or varicose veins > 7 mm is also identified in the exclusions as not medically necessary, and treatment of incompetent perforator veins is excluded except when a venous ulcer or history of venous ulcer is present to prevent recurrence.

Endovenous mechanochemical ablation (MOCA) is described as investigational for Commercial members in the limitations and exclusions section, while the revision history documents that MOCA was added to Medicaid coverage (see revision entry dated May 5, 2025). Providers should note this differential coverage stance when requesting authorization and submit payer-specific documentation accordingly.

Prior language that prohibited procedures when thrombosis would interfere with intraluminal techniques has been removed from the policy. The revision history (May 5, 2025) explicitly notes that the prior note stipulating there should be no thrombosis that would interfere with intraluminal procedures was removed; current policy text in this excerpt does not restate that exclusion.

Sclerotherapy of spider veins and small varicosities is characterized in the policy as generally cosmetic and not medically necessary. The limitations state that injections for reticular veins, telangiectasia or visible subcuticular veins < 4 mm are considered cosmetic (CPT codes: 36468, 36469), aligning sclerotherapy for these small-caliber lesions with noncoverage.

The policy revision history documents removal of several prior prerequisites. Notably, the requirement for a 3‑month trial of conservative non‑operative treatment (leg elevation, compression stockings) as a prerequisite for procedures was removed, and other prior timing restrictions related to sclerotherapy after ablation were also eliminated. Providers should follow the updated criteria and supply documentation per the current policy rather than relying on removed prerequisites.

Procedure, Imaging, and Diagnosis Codes

Covered CPT/HCPCS Procedure and Imaging CodesmixedCovered

36465	Injection of non-compounded foam sclerosant with ultrasound compression maneuvers; single incompetent truncal vein (inclusive of imaging)
36466	Injection of non-compounded foam sclerosant; multiple incompetent truncal veins, same leg (inclusive of imaging)
36470	Injection of sclerosant; single incompetent vein (other than telangiectasia)
36471	Injection of sclerosing solution; multiple incompetent veins, same leg
36473	Endovenous mechanochemical ablation; first vein treated (Medicaid and Medicare members only)
36474	Endovenous mechanochemical ablation; subsequent vein(s) treated (Medicaid and Medicare members only)
36475	Endovenous radiofrequency ablation; first vein treated
36476	Endovenous radiofrequency ablation; subsequent vein(s) treated
36478	Endovenous laser ablation; first vein treated
36479	Endovenous laser ablation; subsequent vein(s) treated

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Cosmetic / Not Medically Necessary Procedure CodesCPTNot Covered

36468	Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk
36469	Injection of sclerosant for telangiectasia (when billed separately)
Transdermal laser/photodermal sclerosis	Transdermal laser therapy and photodermal sclerosis (not coded as specific CPT here)

ICD-10 Diagnosis Codes (core list)ICD-10

I80.00	Phlebitis and thrombophlebitis of superficial vessels of unspecified lower extremity
I80.01	Phlebitis and thrombophlebitis of superficial vessels of right lower extremity
I80.02	Phlebitis and thrombophlebitis of superficial vessels of left lower extremity
I80.03	Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateral
I80.10	Phlebitis and thrombophlebitis of unspecified femoral vein
I80.11	Phlebitis and thrombophlebitis of right femoral vein
I80.12	Phlebitis and thrombophlebitis of left femoral vein
I80.13	Phlebitis and thrombophlebitis of femoral vein, bilateral
I80.201	Phlebitis and thrombophlebitis of unspecified deep vessels of right lower extremity
I80.202	Phlebitis and thrombophlebitis of unspecified deep vessels of left lower extremity

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ICD-10 Diagnosis Codes (expanded)ICD-10

I80.209	Phlebitis and thrombophlebitis of unspecified deep vessels of unspecified lower extremity
I80.221	Phlebitis and thrombophlebitis of right popliteal vein
I80.222	Phlebitis and thrombophlebitis of left popliteal vein
I80.223	Phlebitis and thrombophlebitis of popliteal vein, bilateral
I80.229	Phlebitis and thrombophlebitis of unspecified popliteal vein
I80.231	Phlebitis and thrombophlebitis of right tibial vein
I80.232	Phlebitis and thrombophlebitis of left tibial vein
I80.233	Phlebitis and thrombophlebitis of tibial vein, bilateral
I80.239	Phlebitis and thrombophlebitis of unspecified tibial vein
I80.241	Phlebitis and thrombophlebitis of right peroneal vein

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Accessory saphenous reflux time — > 500 msec (coding/threshold)

Accessory saphenous reflux time> 500 msec

Maximum vein diameters — ELAS 20 mm; RFA 18 mm.

Maximum vein diametersELAS 20 mm; RFA 18 mm

Accessory saphenous reflux time — > 500 msec (redundant reference in revisions).

Accessory saphenous reflux time> 500 msec

Recurrent episode timeframe — 90 days (revised).

Recurrent episode timeframe

Prior Authorization, Documentation, and Operational Notes

Prior Authorization

Prior Authorization Required — Imaging

Prior authorization is required for the procedures covered by this policy. Pretreatment venous Doppler or duplex ultrasound must be performed and submitted with the authorization request to localize sites of incompetence. At least one post-treatment Doppler/duplex study is required and will be reviewed as part of continued authorization or additional treatment requests.

Pretreatment venous Doppler/duplex required (submit with PA request)
At least one post-treatment Doppler/duplex study required
Failure to submit imaging may prevent proper preauthorization or payment

Prior Authorization

Prior Authorization Considerations

Policy revisions have expanded covered services (e.g., mechanochemical ablation [MOCA], subfascial endoscopic perforator vein surgery) and updated prerequisites for authorization. Providers should verify member benefits and submit documentation that demonstrates the member meets the current medical necessity criteria.

Coverage expansions included: MOCA and subfascial endoscopic perforator vein surgery (see revision history)

Clinical Background and Rationale

Venous insufficiency arises from venous hypertension and reflux due to incompetent one‑way valves, producing elongated, rope‑like, bulging varicose veins. Great saphenous vein reflux is a common contributor. Clinical manifestations range from cosmetic bulging veins to symptoms such as pain, swelling, itching or burning, recurrent superficial thrombophlebitis, hemorrhage from ruptured varicosities, and complications including venous stasis ulcers. Treatment options span conservative measures (compression, elevation, analgesics) to surgical and endovenous interventions targeted at eliminating reflux; the policy revision history also notes practice‑level updates (for example, defined reflux timing thresholds) that affect procedural eligibility and documentation expectations.

Key Terms and Procedural Definitions

Venous insufficiency / varicose veins — Definition and brief description (inv-26)

DefinitionVenous insufficiency is caused by venous hypertension and reflux from incompetent one-way valves, producing elongated, rope-like, bulged varicose veins.

Common causeGreat saphenous vein reflux leading to pooling in visible varicose veins.

Treatment rangeConservative care (compression, elevation, analgesics) to surgical and endovenous procedures directed at correcting reflux.

Cyanoacrylate embolization (CAE) — Definition (inv-27)

DefinitionCyanoacrylate embolization (CAE) is a minimally invasive, non-tumescent, non-thermal, non-sclerosant endovenous procedure that uses a medical adhesive to close the diseased vein (e.g., VenaSeal).

Also known as