CurrentHealthPartnersPolicy N/A

Prior Authorization for Varicose Vein Procedures of the lower extremities

This form/policy governs prior authorization requirements and limits for lower-extremity varicose vein procedures (endovenous thermal/non-thermal ablation and chemical sclerotherapy) for HealthPartners members, including required documentation and per-leg session limits within six-month periods.

Policy Summary

PayerHealthPartners

PolicyPrior Authorization for Varicose Vein Procedures of the lower extremities

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionFax completed forms to (952)853-8713 or call UM at (952)883-6333; include full member/requester/physician/facility information and submit required clinical documentation (duplex ultrasound report with interpretation, treatment plan, CPT codes, treatment location, and prior treatment dates).

SourceLink

POLICY UPDATE CHANGES

No material changes

1Max thermal/non-thermal sessions per leg per 6 months

2Max chemical ablation sessions per leg per 6 months

1Required completed prior authorization form

Coverage Summary

Medical Necessity / Prior Authorization Criteria

General Prior Authorization / Medical Necessity Requirements

Covered when ALL of the following are met:

General requirements

Completed form: Request is submitted with completed prior authorization form and required member/requester/physician/facility information
Incomplete forms will be returned
Clinical documentation is submitted to support the request
Include duplex ultrasound report results with interpretation, clear description of intended treatment plan, applicable CPT codes, and detailed location of treatment
Diagnosis codes provided: Primary and any secondary diagnosis codes are provided
Urgency: If urgent, submit clinical reason for urgency showing waiting the standard review time would seriously jeopardize member's health, life, or ability to regain maximum functioning

Endovenous thermal or non-thermal ablation procedural limits

Coverage is limited under the following quantity rule:

Thermal/non-thermal ablation procedural limits

Per-leg session limit: Treatment sessions are limited to a maximum of one treatment session per affected leg within a six-month period when medical criteria are met<= 1 session per affected leg per 6 months
Provider reporting - procedure details: Provider must list primary procedure CPT code, units, description/location (right, left, bilateral), and vein being treated
Provider reporting - prior treatments: Provider must list previous vein treatment(s) and dates

Endovenous chemical ablation (liquid or foam sclerotherapy) procedural limits

Coverage is limited under the following quantity rule:

Chemical ablation procedural limits

Per-leg session limit: Chemical ablation is limited to a maximum of two treatment sessions per affected leg within a six-month period when medical criteria are met<= 2 sessions per affected leg per 6 months
Sclerosing agent reimbursement: The sclerosing agent is included in the procedure and will not be reimbursed separately
Provider reporting - procedure details: Provider must list primary procedure CPT code, units, description/location (right, left, bilateral), vein being treated, and number of sessions requested

Provider Actions & Requirements

Prior Authorization

Submit prior authorization request

Fax completed prior authorization forms to (952)853-8713 or call Utilization Management at (952)883-6333. You may also sign in at healthpartners.com/provider and use the Authorizations and referrals link to check status. Include full member, requester, physician, and facility information on the submission.

Documentation Required

Submit supporting clinical documentation

Provide duplex ultrasound report results with interpretation, a clear description of the intended treatment plan, applicable procedure (CPT) codes for the planned interventions, detailed location of treatment, and prior vein treatment(s) with dates to support the request.

Duplex ultrasound report with interpretation
Description of intended treatment plan
Applicable CPT/procedure codes for planned interventions
Detailed treatment location (right, left, bilateral; specific vein)
Previous vein treatments and dates

Billing Rule

Sclerosing agent not reimbursed separately

For endovenous chemical ablation (liquid or foam sclerotherapy), the sclerosing agent is included as part of the procedure and will not be reimbursed separately.

Denial Risk

Incomplete or incorrect claim information may be rejected

Claims may be rejected or forms returned if key billing information is incorrect or incomplete. Ensure clinic tax ID and billing tax ID are accurate (claim may be rejected if incorrect) and submit a completed prior authorization form to avoid return of the request.

Background & Definitions

This prior authorization form establishes the administrative and clinical documentation requirements for authorization of lower-extremity varicose vein procedures. Providers must submit a completed prior authorization form with full member, requester, physician, and facility information (claims may be rejected if clinic or billing tax ID is incorrect), and include clinical documentation such as duplex ultrasound report results with interpretation, a clear description of the intended treatment plan, applicable CPT procedure codes, detailed treatment location, prior vein treatment(s) and dates, and urgency justification if applicable. Fax completed forms to (952)853-8713 or call Utilization Management at (952)883-6333 and check status at healthpartners.com/provider.

Term	Definition
Endovenous chemical ablation	Liquid or foam sclerotherapy; sclerosing agent included in procedure and not separately reimbursed.
Treatment session	A single procedural intervention on an affected leg; limits apply per leg within six-month periods.