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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyHealth New England Varicose Vein Coverage | OpenPa…
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    ModifiedHealth-New-EnglandPolicy UM727POL

    Treatment for Varicose Veins and Venous Insufficiency - Medical Policy

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    This policy governs Health New England coverage and prior-authorization handling for procedures used to treat lower-extremity varicose veins, venous reflux, and venous insufficiency across Commercial, Medicare Advantage, and Medicaid (BeHealthy) lines of business.

    Policy Summary
    PayerHealth-New-England
    PolicyTreatment for Varicose Veins and Venous Insufficiency
    Policy CodePolicy UM727POL
    Change TypeModified
    Effective DateFeb 1, 2027
    Next Review DateN/A
    Key ActionSubmit applicable procedures for prior authorization with clinical evidence demonstrating that the adopted criteria are met.
    SourceLink
    POLICY UPDATE CHANGES

    Prior authorization was added for CPT codes 36471, 36473, 36474, 37700, 37718, 37722, and 37780.

    Commercial-line coverage status changed for CPT codes 36482, 36483, 36473, and 36474 from non-covered to covered with prior authorization.

    InterQual criteria were adopted for commercial lines of business and subsequently for Medicare procedures involving treatment of lower-extremity varicose veins.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    3Applicable lines of business
    7Prior authorization added
    4Commercial codes covered with prior authorization
    36468Spider-vein injection code not covered

    Covered Services and Medical Necessity Criteria

    Endovenous ablation and UGFS

    Coverage is evaluated using the applicable adopted InterQual criteria.

    Endovenous treatment criteria

    • For cyanoacrylate closure, endovenous ablation, endovenous laser ablation (EVLA), endovenous nonthermal ablation, endovenous thermal ablation, mechanochemical ablation (MOCA), radiofrequency ablation (RFA), or ultrasound-guided foam sclerotherapy (UGFS), apply the applicable Commercial or Medicaid CP criteria for lower-extremity superficial truncal or perforator vein ablation, or the applicable Medicare criteria for NTNT polidocanol microfoam, NTNT technique, or RFA/EVLA.

    Phlebectomy procedures

    Coverage is evaluated using the adopted InterQual criteria.

    Phlebectomy criteria

    • For ambulatory phlebectomy, ambulatory selective variceal ablation under local anesthesia (ASVAL), hook phlebectomy, microphlebectomy, mini phlebectomy, stab avulsion, stab phlebectomy, or transilluminated powered phlebectomy (TIPP), apply the applicable Commercial or Medicaid CP criteria for lower-extremity superficial tributary varicose vein phlebectomy, or the Medicare criterion for compression sclerotherapy or microphlebectomy.

    Ligation, stripping, or excision

    Coverage is evaluated using the adopted InterQual criteria.

    Ligation and stripping criteria

    • For ligation and division with or without stripping or excision of a superficial vein, apply the applicable Commercial or Medicaid CP criteria for lower-extremity superficial vein ligation and division with or without stripping or excision, or the Medicare criterion for ligation with or without stripping.

    Foam and microfoam sclerotherapy

    Coverage is evaluated using the adopted InterQual criteria.

    Sclerotherapy criteria

    • For foam sclerotherapy, microfoam sclerotherapy, or ultrasound-guided foam sclerotherapy (UGFS), apply the applicable Commercial or Medicaid CP criterion for lower-extremity superficial tributary varicose vein sclerotherapy, or the Medicare criteria for compression sclerotherapy or microphlebectomy and NTNT polidocanol microfoam (PEM).

    Injection of sclerosant for spider veins (telangiectasia) of the limb or trunk, reported with CPT 36468, is not a covered benefit.

    A determination that a service or supply is medically necessary does not guarantee coverage or payment. The member’s benefit program may exclude the service or supply, and the benefit document governs if it conflicts with this policy.

    Cyanoacrylate closure, endovenous ablation, endovenous laser ablation, endovenous nonthermal or thermal ablation, mechanochemical ablation, radiofrequency ablation, and ultrasound-guided foam sclerotherapy are not medically necessary when requested for indications other than those meeting the applicable adopted criteria. Members younger than 18 years are reviewed case by case.

    Ambulatory phlebectomy, ASVAL, hook phlebectomy, microphlebectomy, mini phlebectomy, stab avulsion, stab phlebectomy, and transilluminated powered phlebectomy are not medically necessary when requested for indications other than those meeting the applicable adopted criteria. Members younger than 18 years are reviewed case by case.

    Ligation and division, with or without stripping or excision, of a superficial vein is not medically necessary when requested for indications other than those meeting the applicable adopted criteria. Members younger than 18 years are reviewed case by case.

    Foam sclerotherapy, microfoam sclerotherapy, and ultrasound-guided foam sclerotherapy are not medically necessary when requested for indications other than those meeting the applicable adopted criteria. Members younger than 18 years are reviewed case by case.

    CPT Coding and Coverage Status

    Coding Guidance CPT CodesCPT
    36468Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk
    36470Injection of sclerosant; single incompetent vein (other than telangiectasia)
    36471Injection of sclerosant; multiple incompetent veins (other than telangiectasia)
    36473Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein
    36478Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated
    37700Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions
    37718Ligation, division, and stripping, short saphenous vein
    37722Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below
    37765Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions
    37766Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions
    1–10 of 11
    1/2
    Not CoveredCPTNot Covered
    36468Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk — Not a covered benefit
    Codes Requiring Prior AuthorizationCPT
    36470Injection of sclerosant; single incompetent vein (other than telangiectasia) — PA
    36471Injection of sclerosant; multiple incompetent veins (other than telangiectasia) — PA
    36473Mechanochemical endovenous ablation, first vein — PA
    36478Laser endovenous ablation, first vein treated — PA
    37700Ligation and division of long saphenous vein — PA
    37718Ligation, division, and stripping, short saphenous vein — PA
    37722Ligation, division, and stripping, long saphenous vein — PA
    37780Ligation and division of short saphenous vein — PA
    Codes Not Requiring Prior AuthorizationCPT
    37765Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions — No PA
    37766Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions — No PA
    Procedure codes with prior-authorization historyCPT
    36471Procedure code identified in the policy implementation history as receiving prior-authorization requirements
    36473Procedure code identified as receiving prior authorization; historical commercial and MassHealth coverage-status changes are noted
    36474Procedure code identified as receiving prior authorization; historical commercial and MassHealth coverage-status changes are noted
    37700Procedure code identified in the policy implementation history as receiving prior-authorization requirements
    37718Procedure code identified in the policy implementation history as receiving prior-authorization requirements
    37722Procedure code identified in the policy implementation history as receiving prior-authorization requirements
    37780Procedure code identified in the policy implementation history as receiving prior-authorization requirements
    Commercial codes covered with prior authorizationCPTCovered
    36482Procedure code changed from non-covered to covered with prior authorization for the commercial line of business
    36483Procedure code changed from non-covered to covered with prior authorization for the commercial line of business
    36473Procedure code changed from non-covered to covered with prior authorization for the commercial line of business
    36474Procedure code changed from non-covered to covered with prior authorization for the commercial line of business
    Historical MassHealth non-covered codesCPTNot Covered
    36482Procedure code previously identified as non-covered for MassHealth
    36483Procedure code previously identified as non-covered for MassHealth
    36473Procedure code previously identified as non-covered for MassHealth
    36474Procedure code previously identified as non-covered for MassHealth

    Authorization, Documentation, and Review Requirements

    Documentation Required

    Commercial Procedures Require InterQual Criteria

    For Commercial members, HNE requires use of adopted InterQual criteria for the listed venous procedures. Submit requests under the applicable InterQual procedure criteria.

    • Cyanoacrylate Closure (CAC), Endovenous Ablation, Endovenous Laser Ablation (EVLA), Endovenous Nonthermal Ablation, Endovenous Thermal Ablation, Mechanochemical Ablation (MOCA), Radiofrequency Ablation (RFA), and Ultrasound-Guided Foam Sclerotherapy (UGFS).
    • Applicable InterQual criteria: CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein — Perforator Vein or Superficial Truncal Vein.
    • Ambulatory Phlebectomy, Ambulatory Selective Variceal Ablation Under Local Anesthesia (ASVAL), Hook Phlebectomy, Microphlebectomy, Mini Phlebectomy, Stab Avulsion, Stab Phlebectomy, and Transilluminated Powered Phlebectomy (TIPP): CP:Procedures, Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein — Phlebectomy, Superficial Tributary Varicose Vein.
    • Ligation and division with or without stripping or excision: CP:Procedures, Ligation and Division +/- Stripping or Excision, Lower Extremity Superficial Vein — Ligation and Division +/- Stripping or Excision, Superficial Vein.
    • Foam Sclerotherapy, Microfoam Sclerotherapy, and Ultrasound-Guided Foam Sclerotherapy (UGFS): CP:Procedures, Sclerotherapy, Lower Extremity Superficial Tributary Varicose Vein — Sclerotherapy, Superficial Tributary Varicose Vein.

    Condition Overview

    Varicose veins are dilated and tortuous superficial lower-extremity veins resulting from venous insufficiency, commonly caused by reflux or incompetence of the venous valves. Venous reflux is abnormal backward venous flow that may occur at the saphenofemoral or saphenopopliteal junctions, in perforator veins, or within the deep venous system. Spider veins, or telangiectasias, are dilated capillary veins and are most often treated for cosmetic purposes. Conservative management may include extremity elevation, graded compression, and wound care when indicated; procedural treatment is directed at reducing abnormal pressure transmission and correcting the source of reflux.

    Clinical and Procedural Definitions

    Varicose Veins
    DefinitionDilated, tortuous, superficial vessels of the lower extremities.
    CauseVenous insufficiency resulting from valve reflux or incompetence.
    AppearanceThe vessels protrude from the skin of the lower extremities.
    Spider Veins (Telangiectasias)
    DefinitionDilated capillary veins.
    Common treatment purposeMost often treated for cosmetic purposes.
    Also calledTelangiectasias.
    Policy Summary
    PayerHealth-New-England
    PolicyTreatment for Varicose Veins and Venous Insufficiency
    Policy CodePolicy UM727POL
    Change TypeModified
    Effective DateFeb 1, 2027
    Next Review DateN/A
    Key ActionSubmit applicable procedures for prior authorization with clinical evidence demonstrating that the adopted criteria are met.
    SourceLink
    On This Page
    Covered Services and Medical Necessity CriteriaCPT Coding and Coverage StatusAuthorization, Documentation, and Review RequirementsCondition OverviewClinical and Procedural Definitions
    Documentation Required

    Medicaid Procedures Require InterQual Criteria

    For Medicaid members enrolled through BeHealthy, HNE requires use of adopted InterQual criteria for the applicable procedures. Include the relevant procedure and clinical information with the request.

    • Cyanoacrylate Closure (CAC), Endovenous Ablation, Endovenous Laser Ablation (EVLA), Endovenous Nonthermal Ablation, Endovenous Thermal Ablation, Mechanochemical Ablation (MOCA), and Radiofrequency Ablation (RFA).
    • Applicable criteria: CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein — Perforator Vein or Superficial Truncal Vein.
    • The source also identifies the adopted InterQual criteria for these procedures under the Medicaid BeHealthy line of business.
    Prior Authorization

    Prior Authorization for Selected Procedures

    Obtain prior authorization before submitting requests for selected varicose-vein and venous-insufficiency procedures. Verify the member's line of business and benefit requirements before performing the service.

    • Prior authorization applies to covered procedure codes identified as PA in the coding guidance, including 36470, 36471, 36473, 36474, 36478, 36482, 36483, 37700, 37718, 37722, and 37780, as applicable.
    • CPT 36468 is not a covered benefit. CPT 37765 and 37766 are identified as not requiring prior authorization.
    • Use the applicable Commercial, Medicaid, or Medicare clinical criteria in addition to obtaining authorization.
    Billing Rule

    Apply Line-of-Business Criteria

    Apply criteria according to the member's line of business. Commercial and Medicaid requests use the adopted HNE InterQual criteria, while Medicare requests use the Medicare-specific InterQual criteria identified in the policy.

    • Commercial and Medicaid: use the applicable CP:Procedures InterQual criteria for endovenous ablation, phlebectomy, ligation or stripping, and sclerotherapy procedures.
    • Medicare endovenous procedures: Medicare: Procedures, Varicose Veins of the Lower Extremity, Treatment of Wellpoint — NTNT Polidocanol Microfoam (PEM), NTNT Technique, or RFA/EVLA, as applicable.
    • Medicare phlebectomy and sclerotherapy procedures: Medicare: Procedures, Varicose Veins of the Lower Extremity, Treatment of Wellpoint — Compression Sclerotherapy or Microphlebectomy, or NTNT Polidocanol Microfoam (PEM), as applicable.
    • Medicare ligation or stripping: Medicare: Procedures, Varicose Veins of the Lower Extremity, Treatment of Wellpoint — Ligation +/- Stripping.
    • Members under 18 years of age are reviewed on a case-by-case basis.
    Prior Authorization

    Prior Authorization Requirement Updated

    The policy implementation history added prior authorization requirements for the listed codes. Confirm authorization requirements at the time of service and submit requests before treatment.

    • Added prior authorization: 36471, 36473, 36474, 37700, 37718, 37722, and 37780.
    • Commercial status updates identify CPT 36482 and 36483, as well as 36473 and 36474, as covered with prior authorization for the Commercial line of business.
    • Benefit and line-of-business limitations may result in different coverage or authorization outcomes.
    Documentation Required

    Clinical Evidence Required for Review

    The treating physician or primary care provider must submit clinical evidence showing that the patient meets the applicable criteria for the requested treatment, testing, or surgical procedure. Include sufficient information for HNE to complete prior-authorization review.

    • Submit relevant clinical documentation supporting the diagnosis, indication, requested procedure, and medical necessity.
    • Use the criteria applicable to the member's line of business and requested procedure.
    • HNE's review criteria are based on available clinical information, published evidence, regulatory status, evidence-based guidelines, and other relevant factors.
    Denial Risk

    Endovenous Indication Outside Criteria

    Endovenous ablation procedures are not medically necessary when requested for indications outside the applicable adopted criteria. Requests must document that the indication meets the criteria for the member's line of business.

    • Applies to Cyanoacrylate Closure (CAC), Endovenous Ablation, EVLA, Endovenous Nonthermal Ablation, Endovenous Thermal Ablation, MOCA, RFA, and UGFS.
    • Medicare requests must meet the applicable Medicare InterQual criteria; Commercial and Medicaid requests must meet the applicable CP:Procedures criteria.
    Denial Risk

    Phlebectomy Indication Outside Criteria

    Phlebectomy procedures are not medically necessary when requested for indications outside the applicable adopted criteria. Document the qualifying indication and supporting clinical findings.

    • Applies to Ambulatory Phlebectomy, ASVAL, Hook Phlebectomy, Microphlebectomy, Mini Phlebectomy, Stab Avulsion, Stab Phlebectomy, and TIPP.
    • Commercial and Medicaid criteria use the applicable CP:Procedures Phlebectomy criteria; Medicare uses the applicable Compression Sclerotherapy or Microphlebectomy criteria.
    Denial Risk

    Ligation or Stripping Indication Outside Criteria

    Ligation, stripping, or excision procedures are not medically necessary when requested for indications outside the applicable adopted criteria. Submit documentation supporting the qualifying indication.

    • Applies to Ligation and Division +/- Stripping or Excision of the superficial vein.
    • Commercial and Medicaid criteria use the applicable CP:Procedures Ligation and Division +/- Stripping or Excision criteria; Medicare uses the Ligation +/- Stripping criteria.
    Denial Risk

    Sclerotherapy Indication Outside Criteria

    Foam, microfoam, and ultrasound-guided foam sclerotherapy are not medically necessary when requested for indications outside the applicable adopted criteria. Document the indication and clinical evidence supporting the request.

    • Applies to Foam Sclerotherapy, Microfoam Sclerotherapy, and Ultrasound-Guided Foam Sclerotherapy (UGFS).
    • Commercial and Medicaid criteria use the applicable CP:Procedures Sclerotherapy criteria; Medicare uses the applicable Compression Sclerotherapy or Microphlebectomy and/or NTNT Polidocanol Microfoam criteria.
    Denial Risk

    Insufficient Clinical Evidence May Result in Denial

    Failure to submit the required clinical evidence may prevent HNE from properly reviewing the prior-authorization request and may result in a denial or delay.

    • The treating physician or primary care provider must submit documentation that the patient meets the applicable treatment criteria.
    • Incomplete or missing clinical information creates a risk that medical necessity cannot be established.
    Billing Rule

    Medical-Necessity Approval Does Not Guarantee Payment

    Approval of medical necessity does not guarantee payment. Coverage depends on the member's benefit plan, applicable exclusions, and governing legal or program requirements.

    • Each benefit program defines which services are covered and paid.
    • If the policy guideline conflicts with the member's benefit program, the benefit program governs.
    • Coverage may also be affected by applicable state, federal, CMS, Medicare, or Medicaid requirements.
    Venous Reflux
    DefinitionAbnormal venous flow caused by incompetent valves.
    Common sitesThe saphenofemoral or saphenopopliteal junctions.
    Other affected sitesPerforator veins or the deep venous system.
    Varicose Veins
    DefinitionAbnormally enlarged and tortuous vessels.
    Diameter thresholdGreater than three millimeters in diameter.
    Vessel characteristicsThe vessels are both enlarged and tortuous.
    Endovenous Chemical Ablation
    DefinitionA procedure that uses a medical adhesive to occlude the targeted vein.
    Delivery methodThe medical adhesive is delivered via a catheter.
    Treatment targetThe targeted vein is occluded.
    Endovenous Laser Ablation
    DefinitionA procedure that uses high-intensity laser light to induce photocoagulation of blood and occlusion of the vein.
    Delivery methodThe laser light is delivered through a percutaneous catheter.
    Treatment effectThe treated vein becomes occluded.
    Endovenous Radiofrequency Ablation
    DefinitionA procedure that delivers controlled radiofrequency energy through a catheter inserted into the affected vein.
    MechanismThe generated heat causes the vein to contract.
    Treatment effectThe vein becomes occluded.
    Ablation
    DefinitionRemoval or destruction of a body part, function, or tissue.
    MethodsMay be performed via surgery, drugs, radiofrequency energy, hormones, or heat.
    ScopeOther methods may also be used to remove or destroy the body part, function, or tissue.
    Radiofrequency Energy
    DefinitionEnergy in the form of radio waves.
    NatureIt acts as electrical energy.
    UsesIt can sculpt, shrink, or remove soft tissue.