CurrentPriority Health MedicarePolicy 91326

Varicose Vein Treatment

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This policy governs coverage of lower-extremity varicose vein treatment, including ablation, sclerotherapy, phlebectomy, ligation and division, and subfascial endoscopic perforator surgery, subject to InterQual criteria, member benefits, and applicable CMS requirements.

Policy Summary

PayerPriority Health Medicare

PolicyVaricose Vein Treatment

Policy CodePolicy N/A

Change TypeAdministrative and template updatesno material clinical or coverage change

Effective Date09/01/2026

Next Review DateN/A

Key ActionSubmit prior authorization requests demonstrating medical necessity when required and verify applicable InterQual criteria.

SourceLink

POLICY UPDATE CHANGES

The guidelines table in section IV was completed and corresponding citations were added to section IX.

The policy was moved to an enhanced, expanded template.

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CurrentPriority Health MedicarePolicy 91326

Varicose Vein Treatment

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Sign up for priority_health_medicare Policy 91326 alerts

Get alerted when Policy 91326 changes without checking for updates manually.

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Policy Summary

PayerPriority Health Medicare

PolicyVaricose Vein Treatment

Policy CodePolicy N/A

Change TypeAdministrative and template updatesno material clinical or coverage change

Effective Date09/01/2026

Next Review DateN/A

Key ActionSubmit prior authorization requests demonstrating medical necessity when required and verify applicable InterQual criteria.

SourceLink

POLICY UPDATE CHANGES

The guidelines table in section IV was completed and corresponding citations were added to section IX.

The policy was moved to an enhanced, expanded template.

5Potentially medically necessary treatment categories

20Procedures subject to InterQual criteria

2Diagnosis categories not medically necessary

1Not separately payable codes

8Endovenous ablation modalities

Medical Necessity and Coverage Criteria

Medical Necessity Criteria

Priority Health may consider the following procedures for treatment of varicose veins medically necessary when the applicable InterQual® criteria are met.

ALL of the following

The applicable InterQual® medical-necessity criteria are met.
Access InterQual guidelines through Priority Health Prism: Authorizations → Authorization Criteria Lookup.
ONE of the following procedure categories
- - Cyanoacrylate closure (CAC)
  - Endovenous ablation
  - Endovenous laser ablation (EVLA)
  - Endovenous nonthermal ablation
  - Endovenous thermal ablation
  - Mechanochemical ablation (MOCA)
  - Radiofrequency ablation (RFA)
  - Ultrasound-guided foam sclerotherapy (UGFS)
- - Foam sclerotherapy
  - Microfoam sclerotherapy
  - Ultrasound-guided foam sclerotherapy (UGFS)
- Subfascial endoscopic perforator surgery (SEPS)
- Ligation and division, with or without stripping or excision, of a lower-extremity superficial vein
- - Ambulatory phlebectomy
  - Ambulatory selective variceal ablation under local anesthesia (ASVAL)
  - Hook phlebectomy
  - Microphlebectomy
  - Mini phlebectomy
  - Stab avulsion
  - Stab phlebectomy
  - Transilluminated powered phlebectomy (TIPP)

Treatment of asymptomatic varicose veins of the lower extremity and cosmetic surgery are excluded from medical necessity. Diagnoses considered not medically necessary include ICD-10-CM codes I83.90–I83.93 (asymptomatic varicose veins of lower extremity) and Z41.1 (encounter for cosmetic surgery).

The following procedures are considered not medically necessary or have coding limitations: CPT 36468 for injections of sclerosant for spider veins (telangiectasia), limb or trunk; CPT 37799 (unlisted vascular surgery procedure) when billed for Transilluminated Powered Phlebectomy; and Category III CPT 0524T for endovenous catheter-directed chemical ablation with balloon isolation of an incompetent extremity vein, including vascular access, catheter manipulation, diagnostic imaging, imaging guidance, and monitoring.

CPT 37799 may be covered when used for stab phlebectomy involving fewer than 10 stab incisions; explanatory notes must accompany the claim.

Experimental, investigational, or unproven treatment is excluded from coverage. Individual case review may allow coverage for care or treatment that is investigational yet promising for the condition. Requests for individual consideration require prior plan approval, and determinations are made by a Priority Health medical director or clinical pharmacist.

The exclusion may be reviewed for an exception when the condition is a terminal illness or a chronic, life-threatening, severely disabling disease causing serious clinical deterioration.

Treatment for asymptomatic varicose veins or cosmetic surgery is not medically necessary and is not covered under these criteria. This includes asymptomatic lower-extremity varicose veins (I83.90–I83.93) and encounters for cosmetic surgery (Z41.1).

The following procedures are considered not medically necessary: injections of sclerosant for spider veins (telangiectasia) of the limb or trunk (36468), Transilluminated Powered Phlebectomy when billed with unlisted vascular surgery code 37799, and endovenous catheter-directed chemical ablation with balloon isolation of an incompetent extremity vein (0524T).

When CPT 37799 is billed for stab phlebectomy involving fewer than 10 stab incisions, it may be covered if explanatory notes accompany the claim.

CPT and Diagnosis Coding

Diagnoses considered not medically necessaryICD-10Not Covered

I83.90-I83.93	Asymptomatic varicose veins of lower extremity
Z41.1	Encounter for cosmetic surgery

Procedures considered not medically necessaryCPTNot Covered

36468	Injections of sclerosant for spider veins (telangiectasia); limb or trunk
37799	Unlisted procedure, vascular surgery if billed for Transilluminated Powered Phlebectomy; Covered for stab phlebectomy if less than 10 stab incision. (Explanatory notes must accompany claim)
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

CPT codes subject to InterQual criteria reviewCPTCovered

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 (eg, great saphenous vein, accessory saphenous vein)
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 (e.g., great saphenous vein, accessory saphenous vein), same leg
36470	Injection of sclerosing solution; single incompetent vein (other than telangiectasia)
36471	Injection of sclerosing solution; multiple incompetent veins (other than telangiectasia), same leg

CPT codes subject to InterQual criteria reviewCPTCovered

36473	Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated
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)
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)
36478	Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated
36479	Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)
36482	Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (e.g., cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated
36483	Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (e.g., cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

CPT codes subject to InterQual criteria: SclerotherapyCPT

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 (eg, great saphenous vein, accessory saphenous vein)
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 (e.g., great saphenous vein, accessory saphenous vein), same leg
36470	Injection of sclerosing solution; single incompetent vein (other than telangiectasia)
36471	Injection of sclerosing solution; multiple incompetent veins (other than telangiectasia), same leg

CPT codes subject to InterQual criteria: Endovenous ablationCPT

36473	Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated
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)
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)
36478	Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated
36479	Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)
36482	Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (e.g., cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated
36483	Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (e.g., cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

CPT codes subject to InterQual criteria: Surgical treatment and ultrasound guidanceCPT

37700	Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions
37718	Ligation, division, and stripping, short saphenous vein
37722	Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below
37765	Stab phlebectomy of varicose veins, one extremity; 10-20 stab incisions
37766	Stab phlebectomy of varicose veins, one extremity; more than 20 incisions division, and/or excision of varicose vein cluster(s), one leg
37780	Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure)
37785	Ligation, division, and/or excision of varicose vein cluster(s), one leg
76942	Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation

Other related CPT codesCPT

75820	Venography, extremity, unilateral, radiological supervision and interpretation
75822	Venography, extremity, bilateral, radiological supervision and interpretation
36005	Injection procedure for extremity venography (including introduction of needle or intracatheter)
93970	Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study
93971	Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study
37735	Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer and skin graft and/or interruption of communicating veins of lower leg, with excision of deep fascia
37760	Ligation of perforator veins, subfascial, radical (Linton type), with or without skin graft, open
37761	Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg

Not Separately PayableHCPCSNot Covered

S2202

Echosclerotherapy

Authorization, Documentation, and Billing Actions

Prior Authorization

InterQual Criteria Review Required

Priority Health may consider the following varicose-vein procedures medically necessary when the applicable InterQual® criteria are met. Review the criteria before requesting authorization or submitting claims.

Endovenous ablation of lower-extremity superficial truncal or perforator veins: cyanoacrylate closure, endovenous ablation, EVLA, nonthermal or thermal ablation, MOCA, RFA, and UGFS.
Sclerotherapy of lower-extremity superficial tributary varicose veins: foam sclerotherapy, microfoam sclerotherapy, and UGFS.
Subfascial endoscopic perforator surgery (SEPS).
Ligation and division with or without stripping or excision of lower-extremity superficial veins.
Phlebectomy of lower-extremity superficial tributary varicose veins: ambulatory phlebectomy, ASVAL, hook phlebectomy, microphlebectomy, mini phlebectomy, stab avulsion, stab phlebectomy, and TIPP.

Prior Authorization

InterQual Review for Listed Procedures

Clinical Background

Varicose vein treatment primarily targets the superficial venous system. The venous anatomy includes superficial veins, deep veins, and perforator veins, with perforators connecting the superficial and deep systems. Treatment for venous ulcers and skin changes associated with advanced chronic venous disease may involve superficial or perforator veins. The CEAP classification describes chronic venous disorders by clinical manifestations, etiology, anatomy, and pathophysiology; it is not intended to measure disease severity or treatment outcomes.

Clinical Terms and Classifications

Venous anatomy

Superficial veinsLocated below the skin and above the deep fascia; examples include the great saphenous and small saphenous veins.

Perforator veinsConnect the superficial and deep venous systems.

Deep veinsAccompany the main arteries.

CEAP classification

PurposeInternational standard used to describe chronic venous disorders; it is not intended to measure disease severity or treatment outcomes.

Classification dimensionsBased on clinical manifestations, etiologic factors, anatomic distribution, and underlying pathology.

Policy Summary

PayerPriority Health Medicare

PolicyVaricose Vein Treatment

Policy CodePolicy N/A

Change TypeAdministrative and template updatesno material clinical or coverage change

Effective Date09/01/2026

Next Review DateN/A

Key ActionSubmit prior authorization requests demonstrating medical necessity when required and verify applicable InterQual criteria.

SourceLink

On This Page

The listed CPT services are subject to InterQual® criteria review. When prior authorization is required, submit a request demonstrating medical necessity and follow the Priority Health Provider Manual requirements.

CPT 36465, 36466, 36470, and 36471: sclerotherapy and foam-sclerosant injections.
CPT 36473, 36474, 36475, 36476, 36478, 36479, 36482, and 36483: mechanochemical, radiofrequency, laser, and cyanoacrylate endovenous ablation.
CPT 37700, 37718, 37722, 37765, 37766, 37780, and 37785: ligation, stripping, excision, and stab phlebectomy procedures.
CPT 76942: ultrasonic guidance for needle placement.
Verify whether prior authorization is required for the specific service and submit supporting documentation demonstrating medical necessity when required.

Prior Authorization

Prior Approval for Individual Consideration

Individual case review may allow coverage for investigational yet promising care for the conditions described. Requests for individual consideration require prior plan approval; determinations are made by a Priority Health medical director or clinical pharmacist.

An exception to exclusion of experimental, investigational, or unproven treatment may be reviewed for terminal illness or chronic, life-threatening, severely disabling disease causing serious clinical deterioration.

Documentation Required

Explanatory Notes Required for Certain 37799 Claims

When billing CPT 37799 for stab phlebectomy with fewer than 10 stab incisions, include explanatory notes with the claim.

CPT 37799 is an unlisted vascular-surgery procedure code.
The code is not covered when billed for Transilluminated Powered Phlebectomy (TIPP).

Documentation Required

Medical-Necessity Submission Requirements

When prior authorization is required, providers must submit a request demonstrating that the drug, service, or procedure is medically necessary. Refer to the Priority Health Provider Manual for additional process requirements.

Include clinical documentation supporting the requested service and its medical necessity.
Obtain prior plan approval for requests seeking individual consideration of investigational yet promising care.

Unsupported block type: info

Denial Risk

Asymptomatic or Cosmetic Indications

Treatment of asymptomatic varicose veins or cosmetic indications is considered not medically necessary and may be denied.

ICD-10-CM I83.90–I83.93: asymptomatic varicose veins of the lower extremity.
ICD-10-CM Z41.1: encounter for cosmetic surgery.

Denial Risk

Procedures Identified as Not Medically Necessary

The following procedures are considered not medically necessary and are subject to denial, except where the stated CPT 37799 stab-phlebectomy condition is met.

CPT 36468: injections of sclerosant for spider veins (telangiectasia), limb or trunk.
CPT 37799: not medically necessary when billed for Transilluminated Powered Phlebectomy; covered for stab phlebectomy with fewer than 10 stab incisions only when explanatory notes accompany the claim.
CPT 0524T: endovenous catheter-directed chemical ablation with balloon isolation of an incompetent extremity vein.

Note

Verify Benefits and Plan-Document Requirements

Coverage depends on the member's specific benefits and applicable plan documents. Confirm the member's product requirements before providing services or submitting a request; a group-specific policy or controlling plan document may supersede this policy.

Medicare coverage is determined by CMS; if CMS has not adopted a coverage determination, this policy applies.
For HMO/EPO, POS, and PPO plans, consult applicable plan terms; state-mandated benefits and plan documents may govern.
For ASO and individual policies, consult the applicable self-funded plan document or individual insurance policy.
For Medicaid/Healthy Michigan Plan, medical-necessity criteria and the applicable Michigan Medicaid Fee Schedule, Provider Manual, and contract requirements apply.

Billing Rule

Not Separately Payable

Echosclerotherapy is not separately payable. Do not submit it as a separately payable service.

HCPCS S2202: Echosclerotherapy.

C0: no visible or palpable signs; C1: telangiectasias or reticular veins; C2: varicose veins; C3: edema.

Advanced clinical categoriesC4: skin and subcutaneous tissue changes; C5: healed venous ulcer; C6: active venous ulcer.

SubcategoriesC2r: recurrent varicose veins; C4a: pigmentation or eczema; C4b: lipodermatosclerosis or atrophie blanche; C4c: corona phlebectatica; C6r: recurrent active venous ulcer.

Endovenous ablation

TechniqueA minimally invasive technique that uses energy to close incompetent veins from within, typically under ultrasound guidance.

Thermal ablationUses heat from laser or radiofrequency energy to seal varicose veins.

Nonthermal ablationCloses veins without heat, reducing the need for tumescent anesthesia and minimizing nerve injury risk.

Cyanoacrylate closure

TechniqueA nonthermal, non-tumescent endovenous technique.

MaterialUses medical adhesive made of cyanoacrylate glue.

ResultThe adhesive seals the vein shut.

Foam sclerotherapy

Treatment methodInvolves injecting a foamed sclerosant into the vein.

MechanismThe foam displaces blood and causes endothelial damage.

OutcomeEndothelial damage leads to vein closure.

Ambulatory phlebectomy

ProcedureRemoves superficial varicose veins through small skin incisions.

AnesthesiaTypically performed under local anesthesia.

SettingTypically performed in an outpatient setting.