CurrentPremera BluecrossPolicy N/A

Treatment of Varicose Veins/Venous Insufficiency (Coverage Criteria)

Policy governing medical necessity, documentation, and coding for procedural treatments of symptomatic varicose veins and chronic venous insufficiency for Premera Bluecross members.

Policy Summary

PayerPremera Bluecross

PolicyTreatment of Varicose Veins/Venous Insufficiency (coverage criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2025

Next Review DateAug 1, 2025

Key ActionObtain prior authorization with required documentation including venous duplex demonstrating reflux, specific procedure codes, and evidence of ≥3 months of conservative therapy before performing procedural treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=0.5reflux threshold (s)

>=3conservative therapy (months)

4-6sclerotherapy timing (weeks)

RCTs & SRsevidence base for saphenous treatments

15 codeslisted procedure codes

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

policy history entries

Coverage Criteria for Procedural Treatment of Varicose Veins

inv-04: Medical necessity for procedural treatment — Covered when ALL of the following are met

Covered when ALL of the following are met:

ALL of the following

There is documented saphenous reflux on venous testing (for truncal treatments) defined as reflux > 0.5 seconds on duplex ultrasonography; for perforator treatment, demonstrated perforator reflux as defined in policy guidance.> 0.5 seconds
INDICATIONS - one or more must be present
- Ulceration secondary to venous stasis (healed or active)
- Recurrent superficial thrombophlebitis
- Hemorrhage or recurrent bleeding from a ruptured superficial varicosity
- Symptomatic disease
  - Persistent symptoms (eg, pain, aching, heaviness) associated with saphenous reflux that significantly interfere with activities of daily living
  - Conservative management, including graded compression therapy and elevation, has been tried for at least 3 months without adequate improvement
For tributary/varicose tributary treatment: symptoms must be associated with documented truncal or accessory reflux when not performed concomitantly; staged or concomitant phlebectomy or ultrasound-guided foam sclerotherapy (PCF or PEM) is recommended in accordance with society guidance.
For saphenous trunk ablation, treatment is recommended over conservative therapy for symptomatic truncal reflux per SVS/AVF guidance; do not treat asymptomatic CEAP class 1-2 without documented reflux.

inv-05: Modality-specific coverage summaries — Coverage stance by modality based on available evidence

Modality-specific coverage stance based on available evidence and society guidance:

ANY of the following

Endovenous thermal ablation (radiofrequency or laser): Covered for symptomatic saphenous vein reflux when coverage criteria are met; recommended over stripping for GSV/SSV ablation per society guidelines.
Microfoam chemical ablation (Varithena - polidocanol 1%): Covered for treatment of saphenous veins with documented reflux when criteria are met; evidence supports similar occlusion and recurrence outcomes to thermal ablation.
Cyanoacrylate adhesive (VenaSeal): Covered for symptomatic saphenous vein reflux when criteria are met; RCT and cohort data demonstrate noninferiority to thermal ablation up to available follow-up.

inv-06: Perforator vein treatment criteria — When to consider perforator vein treatment

Consider perforator vein treatment when ALL of the following apply:

ALL of the following

Perforator vein reflux is demonstrated on duplex ultrasonography and meets policy-defined thresholds for outward flow and diameter (documented in the medical record).
The individual has CEAP class 4–6 disease (eg, skin changes, healed or active venous ulcer) or persistent/recurrent symptoms after appropriate superficial truncal vein interventions and compression therapy.
Conservative measures including compression therapy and treatment of truncal reflux (if present) have failed to resolve symptoms or ulcers, or perforator treatment is part of an appropriate alternative strategy for refractory disease.

inv-07: Guideline-based coverage criteria for truncal reflux, tributaries, perforators, and ulcers

Coverage criteria aligned with society guidance for truncal reflux, tributaries, perforators, and ulcers:

ALL of the following

Treat symptomatic truncal reflux (GSV, SSV, accessory saphenous veins) with endovenous ablation (thermal or nonthermal) when criteria are met; society guidelines prefer endovenous ablation over stripping for GSV/SSV.
For symptomatic reflux with associated varicosities, ablation of the refluxing trunk plus concomitant phlebectomy or ultrasound-guided foam sclerotherapy (PCF or PEM) is recommended; shared decision-making on timing (simultaneous vs staged) is advised.
Treatment of telangiectasias and reticular veins: sclerotherapy (liquid or foam) is recommended for symptomatic patients; transcutaneous laser may be considered for sclerosant allergy, needle phobia, or small veins (<1 mm) or matting.
Do not perform concomitant initial ablation and treatment of incompetent perforating veins for CEAP class C2 with truncal reflux (recommendation against concomitant treatment).

inv-08: Society-based coverage criteria for truncal ablation and adjunctive treatments

Society recommendations and investigational statements regarding truncal ablation and adjunctive treatments:

ANY of the following

Society guidance (SVS/AVF/AVLS) supports endovenous thermal and nonthermal ablation for symptomatic truncal reflux; concomitant phlebectomy or UGFS is recommended for associated varicosities.
Microfoam Varithena (polidocanol 1%) has demonstrated occlusion rates and clinical outcomes comparable to thermal ablation and is considered an accepted ablation modality when criteria are met.
Mechanochemical ablation (MOCA/ClariVein) — evidence from RCTs shows lower anatomic success at 6–24 months compared with thermal ablation; longer-term durability remains uncertain and current evidence is insufficient to establish superiority. Some policy iterations have listed MOCA as investigational for any vein.
Cyanoacrylate adhesive (VenaSeal) is supported by RCTs and cohort data demonstrating noninferiority to RFA in closure rates up to available follow-up; considered an accepted option when criteria are met.

inv-09: Adjunctive and tributary vein treatments — Treatment options for telangiectasias, reticular veins, and varicose tributaries

Adjunctive and tributary vein treatment coverage and limitations:

ALL of the following

Sclerotherapy (UGFS) using physician-compounded foam or nonstandard preparations for treatment of great, small, or accessory saphenous veins is considered investigational (CPT 36470, 36471) — Varithena (polidocanol 1% microfoam) is the FDA-approved microfoam preparation and is distinguished from physician-compounded foam.
Sclerotherapy (liquid or foam) for symptomatic telangiectasias, reticular veins, and varicose tributaries is covered; treatment solely for cosmetic appearance (eg, spider veins without symptoms or documented reflux) is excluded.
Endovenous ablation procedures of tributary veins are considered investigational; treatment of tributary veins is generally limited to concomitant or staged UGFS or phlebectomy when indicated.
When sclerotherapy is used, appropriate technique, agent, and documented indication should be recorded; physician-compounded foam has variable outcomes and safety concerns compared with standardized microfoam (Varithena).

inv-10: Policy stance excerpts and historical criteria notes

Policy stance excerpts and historical notes (selected):

ANY of the following

Medically necessary: Endovenous thermal ablation, microfoam chemical ablation (Varithena/polidocanol 1%), or cyanoacrylate adhesive (VenaSeal) for symptomatic varicose veins with documented reflux and appropriate indications.
Not medically necessary/investigational: Endovenous chemical ablation with physician-compounded foam or nonmicrofoam preparations for truncal veins; endovenous ablation of tributary veins; mechanochemical ablation (MOCA) and cyanoacrylate/CAE were previously listed investigational in some policy versions but current evidence supports VenaSeal for truncal reflux when criteria met; cryoablation considered not medically necessary based on RCTs.
Cosmetic exclusion: Treatment of telangiectatic dermal veins (spider veins) and procedures performed solely for cosmetic reasons are not covered.

inv-15: COVERAGE CRITERIA — Historical policy replacement and reinstatement notes (ligation/stripping statements)

Historical policy notes (selected):

ANY of the following

Policy revisions over time have clarified that sclerotherapy is medically necessary for accessory and tributary veins when appropriately indicated and that microfoam Varithena is distinguished from physician-compounded foam preparations.
Investigational listings for CAC (VenaSeal) and MOCA were previously present but subsequent evidence and guideline incorporation have led to current coverage positions distinguishing technologies based on evidence strength and FDA status.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for device-based and other venous procedures. Submit the requested CPT codes and supporting clinical documentation (see items) with the prior authorization request. Failure to obtain prior authorization may result in denial.

Include all CPT codes for the planned procedures (e.g., 36465–36476, 36482–36483, 0524T, 0524T variants as applicable).
Provide the specific name of the vein to be treated for each CPT code and laterality (left, right, or bilateral).
Attach a copy of the preoperative venous ultrasound/duplex study demonstrating reflux and identifying the source (saphenofemoral or saphenopopliteal junction, perforator, accessory saphenous, etc.).
Include clinical notes documenting symptoms, prior conservative therapy, and prior treatments.
Document the device/product to be used (e.g., Varithena, VenaSeal) and the FDA status if applicable.

Denial Risk

Coding and Regulatory Identifiers

Listed CPT CodesCPT

0524T	Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or percutaneous, including all vascular access, catheter manipulation, diagnostic imaging; imaging guidance and monitoring.
36465	Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate; inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (great saphenous vein, accessory saphenous vein) (use to report: Varithena/polidocanol 1%).
36466	Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate; inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (great saphenous vein, accessory saphenous vein), same leg (use to report: Varithena/polidocanol 1%).
36468	Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk.
36470	Injection of sclerosing solution; single vein.
36471	Injection of sclerosing solution; multiple veins, same leg.
36473	Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring; percutaneous, mechanochemical; first vein treated (MOCA ClariVein).
36474	Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring; percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) (e.g., MOCA ClariVein).
36475	Endovenous ablation therapy of incompetent vein; extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated.
36476	Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure).

1–10 of 15

1/2

No explicit code lists in this sectionmixed

No codes listed

Regulatory / FDA identifiers and product codesmixed

P140018	FDA premarket approval ID for VenaSeal Closure System (cyanoacrylate adhesive) - product code PJQ
205-098	FDA NDA number for Varithena (polidocanol endovenous microfoam)
K071468	510(k) clearance for ClariVein Infusion Catheter (mechanochemical ablation)
K013635	Predicate device Trellis Infusion System referenced for ClariVein
K882796	Cath Infusion Catheter predicate referenced for ClariVein
GEI	FDA product code for VNUS Closure systems (radiofrequency)
GEX	FDA product code for endovenous laser therapy devices
GEH	FDA product code for cryosurgical units (cryostripping)

Referenced CPT/HCPCS Codes (selected historic mentions)CPT | HCPCS | mixed

36465	Sclerotherapy; single session (documented in history as added 1/1/18)
36466	Sclerotherapy; multiple sessions (added 1/1/18)
36470	Sclerotherapy, with thrombosis of great saphenous; referenced as investigational for certain agents
36471	Sclerotherapy, repeat session; referenced historically (policy changes mention 36471)
36473	Sclerotherapy, foam (added 1/1/17)
36474	Sclerotherapy, additional code (added 1/1/17)
0524T	HCPCS/CPT-like code referenced as added 1/1/19 (new HCPCS code)

inv-24: Moderate to severe reflux — diagnostic threshold

Diagnostic thresholdVenous flow reversal > 0.5 seconds on duplex/Doppler testing (proximal compression, Valsalva, or distal compression/release)

Applied sitesUsed to document pathologic saphenous reflux (great, small, accessory saphenous veins)

Role in coverageRequired element to meet medical necessity for endovenous or chemical ablation of saphenous veins

inv-25: Compression stocking pressure recommendation

Recommended pressure range20-30 mmHg compression stockings (Society for Vascular Surgery/AVF recommendation)

Availability

Definitions and Abbreviations

inv-51: Moderate to severe reflux definition — venous flow reversal > 0.5 seconds

Quantitative thresholdVenous flow reversal > 0.5 seconds (proximal compression, Valsalva, or distal compression/release)

Clinical interpretationConsidered pathologic reflux by most vascular laboratories and required for documenting saphenous reflux

Relevance to coverageThreshold used as a required diagnostic criterion for medical necessity of saphenous vein interventions

inv-52: Compression Therapy — stocking pressure guidance

Stocking pressure guidanceRecommend compression stockings of 20–30 mmHg as first-line conservative therapy for symptomatic varicose veins

Range notedCompression stockings generally effective in a range of 20–40 mmHg; 20–30 mmHg is guideline-preferred

Background and Evidence Summary

Varicose veins are dilated, tortuous superficial veins most commonly of the lower extremities caused by venous valve incompetence leading to reflux and pooling. Clinical manifestations range from cosmetic concerns (telangiectasias) to symptoms such as pain, heaviness, itching, and to complications including superficial thrombophlebitis and venous ulceration. Treatment options span conservative measures (compression, elevation, wound care) to procedural interventions directed at correcting axial reflux and treating symptomatic tributaries.

Policy Revision History

2012-12-11policy_reformatting_and_criteria_revision

Policy reformatted to organize procedures by type of vein and sclerotherapy limited to accessory and tributary veins; tributary treatment criteria clarified including removal of moderate-to-severe saphenous reflux requirement when not done concurrently (effective date referenced in history).

2013-04-08statement_clarification

Clarified sclerotherapy criteria for accessory saphenous veins when not performed concurrently with other treatments and added specific criteria for treatment of tributaries (stab avulsion, hook phlebectomy, sclerotherapy, TIPP).

2016-09-13

Policy Summary

PayerPremera Bluecross

PolicyTreatment of Varicose Veins/Venous Insufficiency (coverage criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2025

Next Review DateAug 1, 2025

SourceLink

On This Page

Physician-compounded foam or other sclerotherapy agents (eg, sodium tetradecyl sulfate, polidocanol injection):

Considered investigational for treatment of great, small, or accessory saphenous veins (CPT 36470, 36471).

Sclerotherapy (liquid or foam) for telangiectasias and reticular veins: Covered for symptomatic telangiectasias and reticular veins per society guidance; treatment of spider veins for cosmetic reasons is excluded.

Sclerotherapy of tributary/varicose tributaries (UGFS with PCF or PEM) or concomitant phlebectomy: Covered when performed concomitantly or within an appropriate staged interval and when symptomatic; SVS/AVF recommend concomitant or staged treatment as clinically indicated.

Endovenous cryoablation: Considered not medically necessary/insufficient evidence for saphenous vein ablation; RCT data indicate inferiority to stripping and inadequate evidence of net health benefit.

Perforator vein ablation may be appropriate for CEAP classes 3–6, particularly for ulcer management or refractory symptoms after superficial procedures and compression therapy.

Cryoablation has RCT evidence indicating inferiority to conventional stripping and is considered not medically necessary for saphenous vein ablation based on current evidence.

Cosmetic Indication — Not Covered

Treatments performed solely for cosmetic indications (e.g., only to improve appearance without significant symptoms or duplex-confirmed reflux) are not covered. When no significant symptoms or reflux are documented, coverage exclusions for cosmetic therapies may apply.

Requests for treatment of telangiectasia or spider veins (cosmetic-level veins) should be identified and will generally be excluded from coverage.
If treatment is requested for appearance alone without duplex-confirmed reflux and documented functional impairment, mark as cosmetic in the submission.

Documentation Required

Duplex-confirmed Reflux and Symptomatic Requirement

Interventions for saphenous or truncal reflux require duplex ultrasound confirmation of pathologic reflux (typically > 0.5 second) and documentation that symptoms are attributable to the reflux. Provide CEAP clinical classification and clearly link reported symptoms to the reflux source.

Include duplex parameters: site and extent of reflux, reflux duration (> 0.5 second when used as the policy threshold), and the anatomic source (GSV, SSV, accessory veins, perforators).
Document the CEAP class (clinical class) and describe how symptoms (pain, swelling, itching, burning, venous stasis ulceration, recurrent thrombophlebitis, hemorrhage) materially affect activities of daily living.
Asymptomatic or mild disease without documented axial reflux is subject to denial or considered not medically necessary.

Prior Authorization

Device-based Procedures — Prior Authorization and Regulatory Status

Prior authorization is required for device-based venous procedures such as cyanoacrylate adhesive (VenaSeal) and proprietary foam sclerosant (Varithena). Provide device name, indication, and FDA clearance/approval status in the request.

If VenaSeal or Varithena is planned, document the FDA product and approval (e.g., VenaSeal PMA P140018; Varithena NDA 205-098).
For other devices (e.g., ClariVein, VNUS, EVLT), include the device name and, if known, the 510(k) clearance information.
When an FDA national coverage decision is absent, the payer may apply its own coverage criteria — document rationale and supporting evidence when applicable.

Documentation Required

Conservative Management Requirement

Conservative management must be attempted and documented before many definitive venous procedures. Documentation should confirm at minimum a trial of compression therapy and other conservative measures as appropriate.

Document conservative measures tried: leg elevation, graded compression (compression stockings) for at least 3 months, analgesics, wound care for ulcers, and any other relevant therapies.
For venous ulceration and symptomatic varicose veins, document use of compression therapy and response; if conservative therapy is insufficient, note decision to proceed to definitive treatment.
If definitive treatment is recommended without compression (per provider judgment and guideline exceptions), include the clinical justification and supporting evidence.

Denial Risk

Documentation and Medicare NCD Absence

Provide the clinical classification and specific clinical findings in the submission. Absence of a Medicare national coverage determination for these procedures means the plan may apply payer-specific medical necessity criteria and deny services that do not meet those criteria.

Document the CEAP clinical classification (C0–C6) and related exam findings in the clinical notes.
If no Medicare NCD exists for the requested procedure, explicitly include supporting literature, guideline references, and a narrative justification tying the patient’s findings to policy criteria.
Be aware that lack of a Medicare NCD can increase risk of payer-specific denial; include robust documentation to demonstrate medical necessity.

Documentation Required

Documentation Expectations and Checklist

Follow the Documentation Requirements table and checklist when submitting requests. Complete, specific documentation reduces the risk of denial for failing to meet medical necessity.

Use the checklist: CPT codes, vein names and laterality, copy of duplex ultrasound, CEAP class, specific indication(s), symptom impact on ADLs, duration and response to conservative therapy, and device/product details.
Provide operative or procedure notes for prior treatments and dates of prior saphenous or tributary procedures if applicable.
When requesting treatment of tributaries following prior saphenous ablation, document timing relative to prior treatment and the reason for additional intervention.

20–30 mmHg stockings are available over the counter without prescription

Role in managementFirst-line conservative therapy for symptomatic varicose veins prior to procedural intervention

inv-26: Conservative therapy duration — minimum duration prior to procedural coverage

Minimum durationConservative management including compression therapy for at least 3 months prior to procedural intervention

Components of conservative careElevation, graded compression, wound care and other nonprocedural measures as clinically appropriate

Documentation expectationMedical record must document failure of conservative management including compression for the minimum duration

inv-27: Vein diameter technical consideration — treatment of veins larger than 12 mm

Technical considerationPerivenous tumescent anesthesia allows successful treatment of veins larger than 12 mm in diameter

Purpose of tumescent anesthesiaReduces thermal injury to adjacent tissue and facilitates effective ablation of large-diameter veins

Implication for planningVein diameter >12 mm does not necessarily preclude endovenous thermal ablation when tumescent technique is used

inv-28: Perforating vein pathology threshold — outward flow and diameter for pathologic perforators

Pathologic perforator criteriaOutward flow duration > 2500 ms (2.5 seconds) AND vein diameter ≥ 2.5 mm when located beneath healed or active ulcers (CEAP C5–C6)

CEAP contextThresholds apply particularly for perforators underlying healed or active venous ulcers (CEAP classes C5–C6)

Treatment implicationSelective treatment of perforators is recommended when these thresholds are met and ulcers are present

inv-29: Definition of moderate to severe reflux (duplicate threshold item)

DefinitionModerate to severe reflux = venous flow reversal for greater than 0.5 seconds with proximal compression, Valsalva, or distal compression and release

Common laboratory practiceMost vascular laboratories consider >0.5 seconds to represent pathologic reflux

Use in policy historyDefinition clarified in prior policy edits (see history) to >0.5 second threshold

Access20–30 mmHg stockings commonly available over the counter

inv-53: Stab avulsion — definition / procedure note

DefinitionStab avulsion (stab/hook phlebectomy): removal of varicose tributary veins through 2–3 mm incisions; veins are hooked and pulled out, wounds closed with tape, leg wrapped in compression

Typical useUsed to remove varicose tributaries at the time of initial treatment or subsequently as adjunctive therapy

Wound careIncisions closed with tapes (not sutures) and compressed postprocedure

inv-54: Saphenous veins and tributaries — anatomical definitions

Included veinsSaphenous veins include great saphenous vein (GSV), small saphenous vein (SSV), and accessory saphenous veins

Tributary veinsTributaries are veins that empty into a larger vein and may be treated by phlebectomy or sclerotherapy

Anatomic noteAccessory saphenous veins travel in parallel with the greater or lesser saphenous veins and are generally 2–2.5 mm normally

inv-55: Venous reflux / venous insufficiency — definition

DefinitionVenous reflux/insufficiency: retrograde blood flow due to one-way valve incompetence causing pooling, varicosities, symptoms (pain, heaviness, itching) and complications (thrombophlebitis, ulcers)

PathophysiologyValve incompetence at any venous level can transmit abnormal pressure from deep to superficial systems leading to reflux

Clinical consequencesChronic venous insufficiency can lead to leg ulceration, hemorrhage, and recurrent thrombophlebitis

inv-56: Superficial truncal veins — list of named veins

Named superficial truncal veinsGreat saphenous vein (GSV), small saphenous vein (SSV), anterior accessory great saphenous vein (AAGSV), posterior accessory great saphenous vein (PAGSV)

ScopeThese are defined as superficial truncal veins in joint SVS/AVLS/AVF guidelines for management and duplex scanning

RelevanceTreatment recommendations frequently reference these named truncal veins for ablation approaches

inv-57: CEAP — classification used to stage chronic venous disease

CEAP meaningCEAP = Clinical, Etiologic, Anatomic, Pathophysiologic classification system used to stage chronic venous disease

Clinical classesClinical C2 = varicose veins through C6 = active ulceration (system ranges C0–C6)

Use in policyCEAP class used to determine appropriateness and thresholds for interventions (e.g., perforator treatment for C5–C6)

inv-58: CEAP abbreviation expanded

Abbreviation expansionCEAP: Clinical, Etiologic, Anatomic, Pathophysiologic

PurposeStandard classification to characterize venous insufficiency features for treatment decisions

ReferenceTable of clinical portion provided in definitions section

inv-59: Common abbreviations (GSV, SSV, UGFS, RFA, EVLA)

GSV/SSVGSV = great saphenous vein; SSV = small saphenous vein

UGFS/RFA/EVLAUGFS = ultrasound-guided foam sclerotherapy; RFA = radiofrequency ablation; EVLA = endovenous laser ablation

Other abbreviationsPCF = physician-compounded foam; PEM = polidocanol endovenous microfoam

inv-60: Compression therapy — historical note

Historical noteCompression therapy was added to Definition of Terms (03/01/17) and has been a longstanding conservative measure in policy history

Role over timePolicy history documents repeated references to compression as initial management and as part of documentation requirements

ImplicationConservative compression expectation has influenced prior authorization and coverage decisions historically

inv-61: MOCA / CAE — investigational categorization historical note

Historical investigational statusMOCA (mechanochemical ablation) and CAE (cyanoacrylate adhesive/embolization) have been listed as investigational in prior policy revisions

Evolving evidencePolicy history notes changing evidence and guideline citations leading to re-evaluation of investigational categorization

Current guidanceRefer to current coverage/modality sections for present stance; historical notes document prior investigational listings

interim_update_perforator_criteria

Interim update added more specific perforator vein criteria (healed or active ulcers and defined measurements of outward flow and vein diameter) and moved policy to new format with prior authorization section added 01/01/17; CPT codes 36473 and 36474 added effective 01/01/17.

2020-07-02policy_deletion_and_replacement

Policy was deleted effective July 2, 2020 and replaced with policy 10.01.530 (history notes deletion and replacement).

2021-12-01code_and_statement_removal

Removed multiple CPT codes (e.g., 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785) and removed investigational statement for sclerotherapy techniques other than microfoam for great/small/accessory saphenous veins at that time.

2022-08-01annual_review

Annual review (approved July 11, 2022) with literature update through March 23, 2022; policy statements unchanged.

2023-03-01interim_review_clarification

Interim review (approved February 20, 2023) clarified that all endovenous ablation procedures of tributary veins are considered investigational and standardized wording from 'patient' to 'individual'.

2023-08-01annual_review_and_clarifying_statements

Annual review (approved July 11, 2023) updated literature through April 4, 2023 and added clarifying statements that endovenous RFA/laser ablation of tributary veins is investigational and reiterated investigational status for certain sclerotherapy techniques of saphenous veins.

2024-06-01interim_review_investigational_update

Interim review (approved June 14, 2024) added statement that endovenous chemical ablation with microfoam sclerotherapy (Varithena/polidocanol 1%) of tributary veins is considered investigational.

2024-08-01annual_review

Annual review (approved July 8, 2024) with literature update through April 5, 2024; policy statements unchanged.

2024-11-01interim_review_sclerotherapy_clarification

Interim review (approved October 21, 2024) refined wording to explicitly list Sotradecol (sodium tetradecyl sulfate), Asclera (polidocanol injection), and physician‑compounded foam as investigational for great, small, or accessory saphenous veins (codes 36470, 36471).

2025-08-01annual_reviewLatest

Annual review (approved July 7, 2025) updated literature through March 13, 2025; policy statements unchanged per history notes (most recent recorded review).