Modifiedpriority healthPolicy 91326-R12

Varicose vein treatment: Endovenous Laser Therapy, Endoluminal Radiofrequency Ablation and Sclerotherapy

Medical policy governing coverage and medical necessity criteria for procedures to treat varicose veins of the lower extremity for Priority Health members, including multiple plan types (HMO/EPO, PPO, POS, ASO, Medicare, Medicaid/Healthy Michigan).

Policy Summary

Payerpriority health

PolicyVaricose vein treatment: Endovenous Laser Therapy, Endoluminal Radiofrequency Ablation and Sclerotherapy

Policy CodePolicy 91326-R12

Change TypeContent additions (governmental regulationsprocedure descriptions)

Effective DateSep 1, 2025

Next Review Date

Key ActionIf prior authorization is required, submit medical necessity documentation per the Priority Health Provider Manual.

SourceLink

POLICY UPDATE CHANGES

Added section II. GOVERNMENTAL REGULATIONS

Added brief descriptions of varicose vein treatment procedures in section IV. DESCRIPTION

2025-09-01Policy effective date

Since 1990Date of origin

MultipleCovered / reviewed codes

~20Procedure CPT codes listed

Coverage Criteria

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.

General coverage condition

Covered when InterQual® criteria are met.

General requirement: Procedure is considered medically necessary when the applicable InterQual® Procedures criteria are met.

InterQual® Procedures criteria were used to determine medical necessity; providers must meet those criteria for coverage.

The following CPT codes are considered not medically necessary and are excluded from coverage when billed: 36468 (injections of sclerosant for spider veins/telangiectasia), 37799 (unlisted procedure, vascular surgery when used to bill Transilluminated Powered Phlebectomy), and 0524T (endovenous catheter-directed chemical ablation with balloon isolation).

This document is provided for informational purposes only and is not an authorization, certification, explanation of benefits, or contract. Coverage and payment for services are subject to the member's plan terms and satisfaction of all plan conditions in effect on the date services are rendered; eligibility and benefit determinations reside with the member's plan.

Note that injections of sclerosant for spider veins (CPT 36468) and procedures billed as unlisted vascular surgery for Transilluminated Powered Phlebectomy (CPT 37799) are not covered as billed. The policy also lists CPT 0524T as not medically necessary when used for endovenous catheter-directed chemical ablation with balloon isolation.

Coding

ICD-10 CodesICD-10

I83.90	Asymptomatic varicose veins of lower extremity
I83.91	Asymptomatic varicose veins of lower extremity
I83.92	Asymptomatic varicose veins of lower extremity
I83.93	Asymptomatic varicose veins of lower extremity
Z41.1	Encounter for cosmetic surgery

CPT codes subject to InterQual reviewCPTCovered

36465	Injection of non-compounded foam sclerosant; single incompetent extremity truncal vein
36466	Injection of non-compounded foam sclerosant; multiple incompetent truncal veins, 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
36473	Endovenous ablation therapy, mechanochemical; first vein treated
36474	Endovenous ablation therapy, mechanochemical; subsequent vein(s) treated
36475	Endovenous ablation therapy, radiofrequency; first vein treated
36476	Endovenous ablation therapy, radiofrequency; second and subsequent veins

Related/other CPT codesCPTCovered

36478	Endovenous ablation therapy, laser; first vein treated
36479	Endovenous ablation therapy, laser; second and subsequent veins
36482	Endovenous ablation therapy by transcatheter delivery of chemical adhesive; first vein
36483	Endovenous ablation therapy by transcatheter delivery of chemical adhesive; subsequent veins
37700	Ligation and division of long saphenous vein at saphenofemoral junction
37718	Ligation, division, and stripping, short saphenous vein
37722	Ligation, division, and stripping, long (greater) saphenous veins
37765	Stab phlebectomy of varicose veins; 10-20 stab incisions
37766	Stab phlebectomy of varicose veins; more than 20 incisions
37780	Ligation and division of short saphenous vein at saphenopopliteal junction

1–10 of 20

1/2

Not medically necessary codesCPTNot Covered

36468	Injections of sclerosant for spider veins (telangiectasia); limb or trunk - noted as not medically necessary
37799	Unlisted procedure, vascular surgery if billed for Transilluminated Powered Phlebectomy
0524T	Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein - listed as not medically necessary

Varicose vein procedure CPT codes (endovenous and surgical)CPT

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.
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).
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.
37780	Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure).

1–10 of 12

1/2

Additional varicose vein and imaging 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.

Stab phlebectomy incision count

CPT 37765Stab phlebectomy of varicose veins, one extremity; 10-20 stab incisions.

CPT 37766Stab phlebectomy of varicose veins, one extremity; more than 20 incisions.

Usage noteSelect 37765 when 10–20 stab incisions are performed; select 37766 when >20 stab incisions are performed.

Provider Actions & Billing

Prior Authorization

Prior Authorization Required

Prior authorization may be required for certain drugs, services, and procedures. Providers should consult the Priority Health Provider Manual and submit a prior authorization request when required to demonstrate that the requested drug, service, or procedure is medically necessary.

See Priority Health Provider Manual for submission instructions and required documentation.

Note

Prior Authorization Determination

This document is informational and is not an authorization, certification, explanation of benefits, or contract. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage; eligibility and benefit determinations are made according to the member's plan in effect on the date services are rendered.

Note

Provider Responsibility

Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment they choose to provide. Medical policies do not replace clinical judgment and are not intended to limit the plan’s ability to interpret plan language.

Documentation Required

Prior Authorization Documentation

If prior authorization is required, providers must submit supporting clinical documentation demonstrating medical necessity consistent with the Provider Manual. Failure to submit required documentation may result in denial of the request or claim.

Include relevant clinical notes, imaging, prior treatments and responses, and any InterQual® criteria evidence when applicable.

Denial Risk

Not Medically Necessary Codes — Denial Risk

Procedures and codes listed as "considered not medically necessary" will be denied if billed. Providers should review the not medically necessary code list before billing to avoid claim denials.

36468
37799
0524T

Note

Coverage and Eligibility

Receipt of benefits is subject to satisfaction of all terms and conditions of the member's plan. Eligibility and coverage are determined by the member's plan in effect on the date services are rendered.

Definitions

Endovenous Ablation

DefinitionEndovenous Ablation: A minimally invasive technique that uses thermal or nonthermal energy to close off incompetent veins from within, typically under ultrasound guidance.

Typical guidanceProcedures are performed under ultrasound guidance.

PurposeClose incompetent veins to reduce reflux and varicosities.

Endovenous Thermal Ablation

DefinitionEndovenous Thermal Ablation: A category of treatments that use heat — either from laser or radiofrequency energy — to seal off varicose veins.

Energy sourcesIncludes laser (EVLA) and radiofrequency (RFA) modalities.

EffectHeat causes vein wall collapse and subsequent resorption.

EVLA

DefinitionEVLA (Endovenous Laser Ablation): A type of thermal ablation that uses laser energy delivered via a catheter to collapse and seal the affected vein.

ApproachPercutaneous catheter-delivered laser energy applied to the incompetent vein.

Intended outcomeVein collapse and sealing to eliminate reflux.

RFA

DefinitionRFA (Radiofrequency Ablation): A thermal method that uses radiofrequency energy to heat and close the vein wall, leading to vein collapse and resorption.

MechanismRadiofrequency energy heats the vessel wall to induce closure.

Clinical effectResults in vein collapse and eventual resorption.

CAC

DefinitionCAC (Cyanoacrylate Closure): A nonthermal, non-tumescent technique that uses a medical adhesive (cyanoacrylate glue) to seal the vein shut.

CodingReported with endovenous transcatheter chemical adhesive codes (e.g., 36482, 36483) when applicable.

BenefitAvoids thermal energy and tumescent anesthesia, reducing nerve injury risk.

UGFS

DefinitionUGFS (Ultrasound-Guided Foam Sclerotherapy): Foam sclerotherapy performed under ultrasound guidance to treat deeper or less visible varicose veins with greater precision.

TechniqueInjecting foamed sclerosant into the vein to displace blood and induce endothelial damage and closure.

IndicationUsed for deeper or less visible varicose veins where ultrasound guidance improves accuracy.

OpenPayer

Varicose vein treatment: Endovenous Laser Therapy, Endoluminal Radiofrequency Ablation and Sclerotherapy

Coverage Criteria

Coding

Provider Actions & Billing

Background

Definitions