ModifiedUnitedHealthcarePolicy CS117KS.02

Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins (for Kansas Only)

Defines UnitedHealthcare Kansas coverage stance and criteria references for surgical and ablative treatments of varicose veins and venous insufficiency for members in Kansas.

Policy Summary

PayerUnitedHealthcare

PolicySurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins (for Kansas Only)

Policy CodePolicy CS117KS.02

Change TypeMaterial revisions: removed proven language for ligation of perforating veinsCPT code removalsdefinition updates

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionWhen requesting authorization, follow InterQual clinical criteria and document duplex ultrasound findings and device/indication as applicable.

SourceLink

POLICY UPDATE CHANGES

Removed language indicating Ligation, subfascial, endoscopic surgery for treatment of perforating veins associated with chronic Venous Insufficiency is proven and medically necessary in certain circumstances.

Removed definition of Reticular Vein, Spider Vein, and Superficial Thrombophlebitis.

Updated definitions of Great Saphenous Vein and Small Saphenous Vein.

Removed CPT codes 37500 and 37799 from Applicable Codes.

Removed notation pertaining to CPT code 37241.

Updated Description of Services, Clinical Evidence, FDA, and References sections to reflect the most current information.

Kansas onlystate-specific

InterQual referencedprimary criteria

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investigationalVenoValve status

Duplex ultrasounddiagnostic standard

Coverage, Investigational, and Not Covered Statements

Covered, Not Covered, and Investigational Statements

Covered when criteria in InterQual CP for the specified procedures are met; plus the following policy-level statements:

Reconstructive/proven procedures: Varicose vein ablative and stripping procedures are considered reconstructive, proven, and medically necessary in certain circumstances per InterQual criteria.

See InterQual CP: Endovenous Ablation; Ligation and Division +/- Stripping or Excision

Ligation at SFJ to prevent clot propagation: Ligation at the saphenofemoral junction, as a stand‑alone procedure, is proven and medically necessary when used to prevent propagation of an active clot to the deep venous system in individuals with ascending superficial thrombophlebitis who fail or are intolerant of anticoagulation therapy.

Policy‑level explicit approval (see source)

Unproven standalone ligations: Ligation of the GSV at the saphenofemoral junction, SSV at the saphenopopliteal junction, ligation of accessory veins as stand‑alone procedures, and ligation at the saphenofemoral junction as an adjunct to RFA or EVLA are unproven and not medically necessary for treating venous reflux due to insufficient evidence of efficacy.

Policy‑level explicit noncoverage

Ambulatory phlebectomy and sclerotherapy are proven and medically necessary in certain circumstances per InterQual clinical criteria.

Refer to InterQual CP: Phlebectomy; Sclerotherapy

Porcine bioprosthetic valve (VenoValve): Insertion of a porcine bioprosthetic valve (e.g., VenoValve) into the femoral vein for treatment of deep vein reflux is considered unproven and not medically necessary due to insufficient evidence of efficacy.

Investigational device; limited published evidence

Covered when consistent with guidelines and device approvals

Coverage and treatment recommendations summarized from guideline and policy statements present in this section

Exclusions: Treatments for spider veins and/or telangiectasias and endovenous ablation (radiofrequency and/or laser) of reticular or telangiectatic veins are cosmetic/not reconstructive and excluded from coverage.

Coverage limitations and exclusions

Guideline-supported treatments: Endovenous thermal ablation (EVLA/RFA), surgery (ligation and stripping), ultrasound‑guided foam sclerotherapy (UGFS), cyanoacrylate closure (CAC), and mechanochemical ablation are discussed in guidelines; EVTA is recommended as first‑line for GSV/SSV incompetence, UGFS may be considered for trunks <6 mm, and CAC may be considered when a non‑thermal option is preferred.

ESVS, SVS/AVF/AVLS/SIR guidance and NICE summaries

Diagnostic requirement: Duplex ultrasound is the diagnostic test of choice to evaluate venous reflux; reflux defined as >500 ms in superficial truncal veins and pathologic perforators defined as outward flow ≥500 ms and diameter ≥3.5 mm.

SVS/AVF/AVLS/SIR recommendations

InterQual-driven medical necessity determinations

Investigational device — VenoValve

citations':['39']

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Treatments directed at spider veins or telangiectasias are classified as cosmetic and are excluded from coverage. This policy also explicitly excludes endovenous ablation (radiofrequency and/or laser) of reticular or telangiectatic veins because such procedures are not considered reconstructive or medically necessary for coverage purposes.

Endovenous ablation (radiofrequency and/or laser) performed specifically for reticular or telangiectatic veins is excluded from coverage. The policy identifies these indications as cosmetic/nonreconstructive and therefore not medically necessary.

The policy language that previously described ligation, subfascial, and endoscopic surgery for treatment of perforating veins as proven and medically necessary has been removed. For current medical necessity determinations regarding these procedures, refer to the InterQual clinical criteria referenced in the policy.

This policy lists certain procedures and devices as not medically necessary or investigational. Stand-alone ligation of the GSV, SSV, or accessory veins, and ligation performed as an adjunct to radiofrequency or endovenous laser ablation are considered unproven and not medically necessary for treating venous reflux. Likewise, implantation of a porcine bioprosthetic valve (e.g., VenoValve) for deep vein reflux is considered unproven and not medically necessary pending adequate evidence.

The VenoValve porcine bioprosthetic valve is investigational and not FDA approved. Published evidence is limited and early; the device remains under investigation (SAVVE trial NCT04943172) and is not currently an approvable treatment under this policy.

Certain statements that previously appeared in the policy have been removed. Specifically, language asserting that ligation, subfascial, or endoscopic treatment of perforating veins was proven and medically necessary has been deleted; updated InterQual criteria should be used for current determinations.

Applicable Procedure Codes, Coding Thresholds, and Code Changes

Applicable Procedure CPT/HCPCS Codesmixed

0744T	Insertion of bioprosthetic valve, open, femoral vein, including duplex ultrasound imaging guidance, when performed, including autogenous or nonautogenous patch graft (e.g., polyester, ePTFE, bovine pericardium), when performed.
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 (e.g., 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.
36468	Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk.
36470	Injection of sclerosant; single incompetent vein (other than telangiectasia).
36471	Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg.
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.
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; subsequent vein(s) treated in a single extremity, each.

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Referenced device approvalsmixed

K071468	ClariVein infusion catheter (FDA approval referenced).
P140018	VenaSeal Closure System (FDA pre-market approval referenced).

Applicable Codes changedCPT

37500	CPT code removed from Applicable Codes.
37799	CPT code removed from Applicable Codes.
37241	Notation pertaining to this CPT code was removed.

Varicose vein diameter — diagnostic threshold

Threshold>= 3 mm

Clinical correlationCorresponds to CEAP class C2 (varicose veins)

Diagnostic modalityMeasured on duplex ultrasound or clinical exam as dilated subcutaneous tributaries

Pathological reflux time - deep veins — diagnostic threshold

Threshold (deep veins)>= 1.0 sec

DefinitionAbnormal (pathological) reflux time in deep veins defined as reversal of flow lasting at least 1.0 second

Prior Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Prior Authorization Required — Use InterQual

InterQual criteria required — medical necessity for procedures must follow InterQual. UnitedHealthcare uses InterQual® as the primary source for medical necessity determinations for varicose vein procedures. Providers should reference the specific InterQual CP procedures (e.g., Endovenous Ablation, Ligation and Division/Stripping, Phlebectomy, Sclerotherapy) when requesting prior authorization.

Prior authorization decisions will be based on the applicable InterQual® CP criteria.
If InterQual® does not contain applicable criteria, UnitedHealthcare may use other UnitedHealthcare Medical Policies approved by the Kansas Department of Health and Environment.

Documentation Required

Device-Specific Authorization and Documentation

Device-specific authorization and documentation required when using FDA-cleared or FDA-approved devices. When an FDA-cleared or approved device (for example VenaSeal™, ClariVein®, Varithena®) is used, include the device name, model/identifier (when available), and the specific indication in the prior authorization request and operative/procedure documentation. Reference device labeling as needed.

Clinical Background and Rationale

Varicose veins arise from failure of venous valves leading to reflux and venous dilation. Clinically this can cause symptoms ranging from aching and heaviness to skin changes and ulceration. Duplex ultrasound is the diagnostic standard to evaluate reflux and to guide treatment decisions; management options include endovenous thermal ablation, sclerotherapy, mechanochemical ablation, ambulatory phlebectomy, surgical ligation/stripping, and investigational interventions.

Key Definitions and Diagnostic Criteria

Endovenous Ablation definition — procedural definition

DefinitionEndovenous Ablation: a minimally invasive procedure that uses heat generated by radiofrequency (RF) or laser energy to seal off damaged veins

Typical technologiesRadiofrequency (RF) or laser energy modalities referenced

Clinical useUsed to treat superficial truncal vein incompetence (e.g., GSV, SSV) per guideline recommendations

Great Saphenous Vein definition — anatomical definition

Anatomical definitionGreat Saphenous Vein: superficial vein originating from medial side of dorsal pedal venous arch, ascends along inside of leg and thigh to join the common femoral vein at the saphenofemoral junction

Clinical relevanceGSV incompetence with axial reflux is a primary target for endovenous ablation therapy

Policy Summary

PayerUnitedHealthcare

PolicySurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins (for Kansas Only)

Policy CodePolicy CS117KS.02

Change TypeMaterial revisions: removed proven language for ligation of perforating veinsCPT code removalsdefinition updates

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionWhen requesting authorization, follow InterQual clinical criteria and document duplex ultrasound findings and device/indication as applicable.

SourceLink

On This Page

Use of FDA‑cleared devices: When using FDA‑cleared/approved devices (for example, VenaSeal, ClariVein, Varithena), ensure the device is used within its approved indication and document device and indication when requesting authorization.

Device approvals and authorization guidance

Diagnostic modalityAssessed using duplex ultrasound

Pathological reflux time - superficial/perforator veins — diagnostic threshold

Threshold (superficial/perforator)>= 0.5 sec

DefinitionAbnormal (pathological) reflux time in superficial and perforator veins defined as reversal of flow lasting at least 0.5 second

Diagnostic modalityAssessed using duplex ultrasound

Duplex reflux duration — reflux definition used in policy

Definition used in policyReflux is defined as reversed flow duration > 500 ms in the superficial truncal veins and selected deep/perforator veins

Equivalent thresholdsPolicy references both >500 ms (SVS/AVF guidance) and the document-specific thresholds (0.5 sec for superficial/perforator, 1.0 sec for deep)

Diagnostic modalityDuplex ultrasound scanning is the diagnostic test of choice to evaluate venous reflux

Pathologic perforator diameter — perforator vein diameter threshold

Perforator diameter threshold>= 3.5 mm

Associated duplex criteriaPathologic perforating veins include outward flow duration >= 500 ms and diameter >= 3.5 mm

Clinical contextApplies to patients with varicose veins (CEAP clinical class C2)

Document device name and indication in the request (e.g., VenaSeal™ Closure System for symptomatic venous reflux diagnosed by duplex ultrasound).
Attach device-specific labeling or FDA documentation when relevant to support the request.

Documentation Required

Imaging Documentation Required

Imaging documentation — preoperative venous duplex ultrasound required. Duplex ultrasound is the gold standard for evaluation of superficial venous incompetence. Prior authorization and medical record documentation should include results of preoperative venous duplex ultrasound to demonstrate anatomy and hemodynamic findings (e.g., reflux, valve dysfunction) that support the requested procedure.

Include duplex ultrasound report/images with lateralization, measured reflux times/velocities, and vein diameters where applicable.
Document correlation of imaging findings with clinical signs/symptoms (CEAP classification or equivalent).

Note

Clinical Selection and Informed Choice

Clinical selection approach — discuss treatment options and select modality consistent with clinician training and device labeling. Providers should discuss available treatment options with the patient, select the modality appropriate for the patient’s clinical presentation and anatomy, and ensure the clinician performing the procedure has appropriate training and experience (including venous ultrasound competence) for the chosen technique.

Document in the chart that options were discussed and why the selected therapy was chosen.
Follow institutional policies for training, consent, and audit when using newer techniques (e.g., cyanoacrylate glue, MOCA).

Note

Reference Benefit Plan Terms — Contract Governs

Reference benefit plan terms and conflicts with contract language. This policy provides guidance for UnitedHealthcare standard benefit plans. Always check the member’s applicable federal, state, or contractual benefit plan terms for coverage specifics. If there is a conflict between this policy and the member’s benefit plan or applicable law/regulation, the benefit plan terms or legal requirements govern.

Confirm member eligibility and specific plan exclusions or limitations before authorization.
When federal or state mandate differs from this policy, follow the mandate.

Denial Risk

Exclusion and Denial Risk — Cosmetic Procedures

Excluded procedures — do not authorize excluded cosmetic treatments. Requests for treatments that are cosmetic or explicitly excluded (e.g., treatments for spider veins/telangiectasias, endovenous ablation of reticular or telangiectatic veins) should be denied per policy.

Do not authorize procedures intended primarily for cosmetic treatment of spider veins/telangiectasias.
Endovenous ablation of reticular or telangiectatic veins is not reconstructive and is excluded from coverage.

Policy noteDefinition updated in the policy history (08/01/2025)

Ligation definition — procedural definition

DefinitionLigation: tying off a vein

Procedural contextMay be performed at junctions (e.g., SFJ or SPJ) for specific indications such as preventing clot propagation

Coverage noteStandalone ligation is considered proven and medically necessary in limited circumstances (e.g., prevent propagation of ascending superficial thrombophlebitis when anticoagulation fails or is not tolerated)

Small Saphenous Vein (SSV) definition — anatomical definition

Anatomical definitionSmall Saphenous Vein (SSV): superficial vein that ascends along the posterior calf to join the popliteal vein in the popliteal fossa in most cases

Clinical relevanceSSV axial reflux is an indication for endovenous ablation when symptomatic

Policy noteSSV definition updated in the policy revisions

Varicose Veins definition — size threshold and CEAP class reference

DefinitionVaricose Veins: dilated subcutaneous tributaries greater than or equal to 3 mm in diameter

CEAP referenceIndividuals with Varicose Veins belong to CEAP clinical class C2

Clinical implicationVaricose veins with axial reflux are considered for endovenous ablation or other interventions per guidelines

Venous Reflux/Insufficiency — pathological reflux time thresholds

Pathological reflux timesDeep veins >= 1.0 sec; Superficial and perforator veins >= 0.5 sec

Duplex guidanceDuplex ultrasound is the diagnostic test of choice to evaluate venous reflux

Clinical applicationUsed to determine candidacy for endovenous ablation, phlebectomy, or sclerotherapy per InterQual and guideline recommendations

Reflux (duplex ultrasound) — reflux duration definition (> 500 ms)

DefinitionReflux (duplex ultrasound) defined as reversed flow duration > 500 ms in the superficial truncal veins and selected deep/perforator veins

Equivalent wordingPolicy notes >500 ms as the minimum value for reversed flow per SVS/AVF guidance

Diagnostic modalityAssessed with duplex ultrasound scanning

Pathologic perforating vein — duplex criteria for perforator veins

Duplex criteriaPathologic perforating vein: outward flow duration >= 500 ms AND diameter >= 3.5 mm on duplex ultrasound

Applies toPatients with varicose veins (CEAP clinical class C2)

Diagnostic modalityDetermined by duplex ultrasound evaluation

Great Saphenous Vein; Small Saphenous Vein — note that definitions were updated in the policy

Updated definitionsGreat Saphenous Vein and Small Saphenous Vein definitions were updated in the policy

Policy history08/01/2025 revision notes document updates to GSV and SSV definitions and removal of several other definitions

ImplicationRefer to the updated definitions in this policy when assessing anatomy for treatment planning