Treatment of Varicose Veins/Venous Insufficiency
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Medical necessity and utilization guidelines for surgical and minimally invasive treatments of varicose veins and venous insufficiency for Scripps Health Plan Services members (Commercial and Medicare Advantage+).
No material clinical or coverage changes in this revision.
Coverage Criteria for Varicose Vein Treatments
Saphenous vein treatment (medically necessary)
Covered when ALL of the following are met
Symptomatic varicose tributaries (medically necessary)
Covered when ALL of the following are met
Perforator veins (medically necessary)
Covered when ALL of the following are met
Investigational / Not medically necessary interventions
Not covered / investigational statements
Isolated treatment of tributary veins without prior or concurrent treatment of saphenous veins is considered investigational. Sclerotherapy techniques other than microfoam sclerotherapy used as the primary therapy for great, small, or accessory saphenous veins are investigational; standard foam sclerotherapy may be used only for small cleanup after a primary saphenous procedure. Stab avulsion, hook phlebectomy, and transilluminated powered phlebectomy of perforator or saphenous veins are considered investigational. Additionally, treatment of telangiectasia (spider veins, angiomata, hemangiomata) under 3 millimeters in diameter is considered not medically necessary and investigational. Mechanochemical ablation (MOCA) and endovenous cryoablation of any vein are listed as investigational.
Combining two otherwise medically necessary treatments during the same session on the same vein or same type of vein (for example, radiofrequency ablation plus microfoam sclerotherapy) is considered not medically necessary. Likewise, microfoam sclerotherapy or cyanoacrylate adhesive used to treat symptomatic tributaries is only permitted when performed during the same session as saphenous vein treatment using the same agent; use of these agents on a different date from saphenous treatment or on the same date when saphenous treatment used a different modality is considered not medically necessary.
Coding and Related Clinical Thresholds
| 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 |
Provider Requirements, Prior Authorization, and Documentation
Prior authorization required for cyanoacrylate (endovenous adhesive) ablation
Prior authorization for cyanoacrylate (endovenous adhesive) ablation is governed by the SHPS utilization management process and must be included in authorization requests when applicable. Include the CPT codes for cyanoacrylate endovenous ablation (36482 for first vein and 36483 for subsequent vein[s] in the same extremity) on requests.
Require ≥6 weeks of compression therapy before saphenous treatment
Conservative management including compression therapy must be attempted for at least 6 weeks before treating symptomatic saphenous reflux unless an exception in the criteria applies (e.g., ulceration, recurrent thrombophlebitis, hemorrhage).
- Confirm and document at least 6 weeks of compression therapy prior to authorization for symptomatic saphenous reflux treatment unless one of the listed urgent indications is present.
Provide diagnostic and clinical documentation: reflux, CEAP class, ADL impact, prior conservative care
Documentation submitted with the request must demonstrate saphenous or perforator reflux, the CEAP classification (CEAP class C2 or greater for saphenous veins), and, when applicable, symptoms that significantly interfere with activities of daily living and prior conservative management.
- Provide diagnostic evidence of reflux (e.g., duplex ultrasound) and state CEAP class.
- If treating for persistent symptoms, document how symptoms interfere with ADLs and that conservative measures (including ≥6 weeks compression) were tried and failed.
Treat all qualifying saphenous veins in same session or document reason
When multiple saphenous veins in the same leg meet the treatment criteria, they must be treated in the same session or the provider must submit documentation explaining why same-session treatment was not performed.
- If not treating all qualifying saphenous veins in the same session, include a documented rationale with the authorization request or postoperative records.
Denial risk if saphenous treatment does not meet listed criteria (CEAP < C2, no documented reflux, or missing conservative care)
Treatment of saphenous veins that does not meet the listed criteria — for example, CEAP class less than C2, lack of documented saphenous reflux, or absence of required prior conservative management — is considered not medically necessary and may be denied.
- Ensure CEAP class ≥ C2 and documented reflux are present and prior conservative therapy requirements are met to avoid denial.
- Treatments not meeting the policy criteria may be denied as not medically necessary.
Denial risk for isolated or improperly timed tributary treatments (microfoam or cyanoacrylate)
Use of microfoam sclerotherapy or cyanoacrylate to treat symptomatic tributaries on a different date than saphenous vein treatment, or on the same date when saphenous treatment used a different modality, is considered not medically necessary and may be denied.
- When microfoam or cyanoacrylate is used for tributaries, it must be during the same session as saphenous treatment using the same agent (or only as leftover product in that session).
- Isolated tributary treatment without prior or concurrent saphenous vein treatment is investigational and may be denied.
Background and Scope
Multiple treatment options exist for varicose veins and venous insufficiency, including surgery (ligation and stripping), thermal endovenous ablation (radiofrequency or laser), sclerotherapy, mechanochemical ablation (MOCA), cyanoacrylate adhesive, and cryoablation. Policy-specific coverage depends on vein type and clinical findings: for saphenous veins the policy requires documentation of saphenous reflux with CEAP class C2 or greater, treatment by a single listed primary procedure, and either ulceration, recurrent superficial thrombophlebitis, hemorrhage from a ruptured varicosity, or persistent symptoms that significantly interfere with activities of daily living after a trial of conservative care including at least 6 weeks of compression therapy. Tributary and perforator treatments have separate criteria and timing requirements; several techniques (including MOCA and endovenous cryoablation) are considered investigational.
Definitions
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