CurrentUnitedHealthcarePolicy CS117.AB

Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins

UnitedHealthcare medical policy CS117.AB governing coverage criteria, exclusions, definitions, and coding guidance for thermal and non-thermal treatments (radiofrequency ablation, endovenous laser ablation, stripping/ligation, foam sclerotherapy, cyanoacrylate adhesive), perforator ablation, ambulatory phlebectomy, and related procedures for venous insufficiency and varicose veins; includes clinical evidence and coding lists. Part 1 of 4 covering policy header, application, medical necessity criteria, exclusions, definitions, sclerotherapy coding limits, and relevant CPT/HCPCS/other codes.

Policy Summary

PayerUnitedHealthcare

PolicySurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins

Policy CodePolicy CS117.AB

Change TypeCoverage revisions and coding updates (material)

Effective Date08/01/2025

Next Review DateN/A

Key ActionObtain and document recent standing or reverse Trendelenburg duplex ultrasound showing vein diameters and reflux duration (report reflux in ms and measurements in mm) to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Removed language indicating ligation, subfascial, endoscopic surgery for perforating veins was proven and medically necessary in certain circumstances.

Removed statement that endovascular embolization using cyanoacrylate-based adhesive is unproven and not medically necessary for treating venous reflux (older language replaced).

Added that ablation of incompetent perforator veins using endovenous foam sclerotherapy and/or cyanoacrylate-based adhesive is unproven and not medically necessary due to insufficient evidence.

Replaced coverage language to include treatment modalities (radiofrequency, laser, stripping with ligation/excision, foam sclerotherapy, cyanoacrylate) for GSV, SSV, and Accessory Veins as reconstructive and medically necessary when criteria met.

Revised duplex ultrasound criterion wording to apply to Accessory Veins (>=500 ms) in addition to GSV and SSV.

Added requirement that incompetent perforator veins are not secondary to acute deep vein thrombosis.

Replaced ambulatory phlebectomy references: added InterQual CP for phlebectomy of superficial tributary veins and removed specific InterQual CP references for various phlebectomy techniques.

Added instruction to refer to CPT 36465 or 36466 per AMA guidance for targeted extremity truncal vein foam sclerosant injections with US-guided compression maneuvers.

Replaced coverage note that CPT code 36468 for spid er veins is cosmetic to explicitly state 36468 is for spider veins/telangiectasias and is considered cosmetic.

Revised coverage limits: CPT codes 36470 and 36471 are covered for sclerotherapy (non-truncal, non-telangiectasia) up to three sessions per leg within a year; previous language had included 36465, 36466.

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

Added definitions for Superficial Vein, Telangiectasias/Spider Veins, and Tributary Vein.

Added statement that benefit coverage is determined by federal, state, or contractual requirements and applicable laws, and medical records may be required for review.

Removed CPT codes 37500 and 37799 from Applicable Codes.

Added instruction that CPT codes 36470 and 36471 are covered up to three sessions per leg within a rolling 12-month period; more than three sessions per leg within a year is cosmetic and excluded.

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500 msReflux duration threshold (GSV/SSV/Accessory)

>=3 mmMinimum trunk vein diameter

>=3.5 mmPerforator vein diameter threshold

3Sclerotherapy sessions allowed (36470/36471)

ExcludedSclerotherapy for spider veins (36468)

multiple RCTsEvidence base

08/01/2025Policy effective date

Coverage Summary

Policy adopts a mixed coverage stance: the initial and subsequent treatment of the Great Saphenous Vein (GSV), Small Saphenous Vein (SSV), and Accessory Veins with radiofrequency ablation (RFA), endovenous laser ablation (EVLA), stripping with ligation and excision, endovenous foam sclerotherapy, and/or cyanoacrylate-based adhesive are considered reconstructive and medically necessary when all listed criteria are met (see duplex and symptom/size thresholds).

Cosmetic exclusions and limits are specified: treatment of spider veins/telangiectasias (CPT 36468) is considered cosmetic and excluded; sclerotherapy using CPT codes 36470 and 36471 is covered for non-truncal, non-telangiectasia veins up to three sessions per leg within a rolling 12-month (365-day) period; AMA-guided use of non-compounded foam with ultrasound maneuvers should be reported with 36465/36466 when applicable.

The policy also clarifies perforator vein treatments: ablation of incompetent perforator veins with RFA or EVLA may be medically necessary when specific perforator criteria are met, but ablation of perforator veins using endovenous foam sclerotherapy and/or cyanoacrylate-based adhesive is considered unproven and not medically necessary due to insufficient evidence.

Administrative and coding updates included in this revision: certain CPT codes were removed from the applicable list, InterQual CP is referenced for ambulatory phlebectomy criteria, and clinicians must follow documentation requirements (e.g., duplex ultrasound in standing or reverse Trendelenburg). Effective date for these policy changes is August 1, 2025.

Medical-Necessity Criteria

Thermal and Non-Thermal Treatments (GSV/SSV/Accessory veins) - Medically Necessary

Thermal and non-thermal treatments of the GSV, SSV, and accessory veins are considered reconstructive and medically necessary when ALL of the following are met:

Individual must have ONE of the following Functional or Physical Impairments: Skin ulceration; Documented episode(s) of frank bleeding of the Varicose Vein due to erosion of/or trauma to the skin; Documented superficial thrombophlebitis; Documented Venous Stasis Dermatitis causing Functional or Physical Impairment; Moderate to Severe Pain causing Functional or Physical Impairment

Venous size requirements: The GSV must be ≥ 3 mm when measured at the proximal thigh immediately below the saphenofemoral junction via Duplex Ultrasonography; The SSV or Accessory Veins must measure ≥ 3 mm in diameter immediately below the appropriate junction via Duplex Ultrasonography

Duplex ultrasound study performed in the standing or reverse Trendelenburg position shows duration of reflux ≥ 500 milliseconds for the GSV, SSV, or Accessory Veins. Note: Duplex ultrasound interpretations stating "moderate to severe reflux" are acceptable.

Ablation of Incompetent Perforator Veins - Medically Necessary

Ablation of incompetent perforator veins using radiofrequency ablation or endovenous laser ablation is considered reconstructive and medically necessary when ALL of the following are met:

Evidence of perforator venous insufficiency measured by a recent duplex ultrasound study performed in the standing or reverse Trendelenburg position

Perforator vein size ≥ 3.5 mm

Perforating vein reflux ≥ 500 milliseconds

Perforating vein lies beneath a healed or active venous stasis ulcer

Not secondary to acute deep vein thrombosis

Ablation of Incompetent Perforator Veins - Not Medically Necessary

The following ablative approaches to incompetent perforator veins are considered unproven and not medically necessary due to insufficient evidence of efficacy:

Ablation using endovenous foam sclerotherapy for perforator veins

Ablation using cyanoacrylate-based adhesive for perforator veins

Sclerotherapy

Sclerotherapy coverage guidance and limits:

Refer to the Applicable Codes section for specific Sclerotherapy code guidance (liquid, foam, ultrasound-guided, endovenous chemical ablation, endovenous microfoam)

Per AMA guidance, if the targeted vein is an extremity truncal vein and injection of non-compounded foam sclerosant with ultrasound-guided compression maneuvers to guide dispersion of the injectate is performed, use CPT codes 36465 and 36466

CPT code 36468 for sclerosant treatment of telangiectasias/spider veins is considered cosmetic and excluded (does not improve a Functional, Physical, or Physiological Impairment)

CPT codes 36470 and 36471 (non-truncal, non-telangiectasia sclerotherapy) are covered up to three sessions per leg within a rolling 12-month period (365 days). More than three sessions per leg within a year is considered cosmetic and excluded

Use CPT codes 36465/36466 for non-compounded foam ultrasound-guided maneuvers targeting truncal extremity veins

Ligation Procedures

Ligation procedures: one proven indication; other listed uses are unproven/not medically necessary for venous reflux.

Proven and medically necessary: Ligation at the saphenofemoral junction, as a stand-alone procedure, 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

Unproven and not medically necessary for treating venous reflux due to insufficient evidence of efficacy: Ligation of the GSV at the saphenofemoral junction as a stand-alone procedure; Ligation of the SSV at the saphenopopliteal junction as a stand-alone procedure; Ligation of accessory veins as a stand-alone procedure; Ligation at the saphenofemoral junction as an adjunct to radiofrequency ablation or endovenous laser ablation of the main saphenous veins

Other Procedures - Not Medically Necessary (Unproven)

Other procedures that are considered unproven and not medically necessary for treating venous reflux:

Endovenous mechanochemical ablation (MOCA) of varicose veins

Porcine bioprosthetic valve implantation (e.g., VenoValve) into the femoral vein for treatment of deep vein reflux associated with chronic venous insufficiency

General coverage statement (revisions summarized)

General coverage statement:

Procedures described in this policy are considered reconstructive and medically necessary when they correct abnormal structure or function and meet the specific medical-necessity criteria detailed in this section

Duplex ultrasound evidence of reflux is required for coverage decisions; superficial and perforator reflux thresholds are ≥ 500 milliseconds (0.5 seconds) as specified in the individual criteria above

Ablation/embolization of perforator veins is covered only as specified under the perforator vein criteria; perforator treatments that are secondary to acute DVT are excluded

Not Covered / Experimental Procedures

Not Covered / Experimental: MOCA, VenoValve, Perforator foam/cyanoacrylate ablation

Intro: Evidence is insufficient for the listed procedures; they are considered not covered/experimental.

ALL of the following

Endovenous mechanochemical ablation (MOCA) of varicose veins is unproven and not medically necessary due to insufficient evidence
Porcine bioprosthetic valve implantation (VenoValve) for deep vein reflux is unproven and not medically necessary due to insufficient evidence
Ablation of incompetent perforator veins using endovenous foam sclerotherapy is unproven and not medically necessary due to insufficient evidence
Ablation of incompetent perforator veins using cyanoacrylate-based adhesive is unproven and not medically necessary due to insufficient evidence

Coding

Endovenous ablation / sclerotherapy / adhesive / foam codes (listed)CPTCovered

0744T	Insertion of bioprosthetic valve, open, femoral vein, including duplex ultrasound imaging guidance, when performed, including autogenous or nonautogenous patch graft
36465	Injection of non-compounded foam sclerosant with ultrasound compression maneuvers; single incompetent extremity truncal vein
36466	Injection of non-compounded foam sclerosant with ultrasound compression maneuvers; multiple incompetent truncal veins, same leg
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, 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; subsequent vein(s) treated
36478	Endovenous ablation therapy, laser; first vein treated

1–10 of 21

1/3

Sclerotherapy for spider veins / telangiectasiaCPTNot Covered

36468

Injection(s) of sclerosant for spider veins (telangiectasia) — cosmetic, excluded

Sclerotherapy session limits (36470/36471)CPTCovered

36470	Covered up to 3 sessions per leg within a rolling 12 months (365 days)
36471	Covered up to 3 sessions per leg within a rolling 12 months (365 days)

Removed CPT codesCPTNot Covered

37500
37799

Sclerotherapy coding guidanceCPT

36465	Use if targeted vein is an extremity truncal vein and injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate is performed (per AMA coding guidance).
36466	As above for multiple truncal veins in the same leg when non-compounded foam sclerosant with ultrasound compression maneuvers is performed.
36468	Sclerosant treatment for spider veins/telangiectasias — considered cosmetic and excluded from coverage.
36470	Sclerotherapy (non-truncal, non-telangiectasia) — covered up to three sessions per leg within a year.
36471	Sclerotherapy (non-truncal, non-telangiectasia) — covered up to three sessions per leg within a year.
37241	Notation pertaining to CPT 37241 was removed from the policy.

Provider Actions

Documentation Required

Duplex ultrasound documentation

Obtain and document a recent duplex ultrasound performed in the standing or reverse Trendelenburg position that includes measured vein diameters and quantification of reflux durations in milliseconds. Acceptable documentation may include duplex interpretations that state "moderate to severe reflux." Ensure the report clearly links reflux measurements to the targeted vessel(s) (e.g., GSV, SSV, accessory, perforator).

Duplex performed standing or reverse Trendelenburg
Document diameters and reflux durations in ms for targeted veins
"Moderate to severe reflux" interpretation is acceptable as meeting reflux documentation requirements

Prior Authorization

Reference InterQual for phlebectomy prior authorization

Reference and follow the InterQual® Clinical Practice (CP) criteria when requesting prior authorization for ambulatory phlebectomy. InterQual criteria will be used to assess medical necessity for phlebectomy procedures.

Background and Evidence Summary

Varicose veins result from valve incompetence causing retrograde flow and venous reflux; pooled clinical and policy sources identify venous reflux and reflux duration as key pathophysiologic features underlying symptoms and complications.

The CEAP classification (Clinical, Etiology, Anatomy, Pathophysiology) is used to grade disease severity from C0 (no visible signs) through C6 (active venous ulcer); visible varicosities correspond to CEAP C2 (vein diameter > 3 mm).

Duplex ultrasonography is described as the gold standard diagnostic test for superficial venous incompetence and is required for documentation: obtain studies in the standing or reverse Trendelenburg position reporting vein diameters and reflux durations (reflux ≥ 500 milliseconds for superficial trunks and accessory veins; perforator reflux and diameter thresholds apply where noted).

Treatment modalities include: thermal endovenous ablation (RFA and EVLA), non-thermal/endovascular options (cyanoacrylate adhesive closure/embolization, polidocanol endovenous microfoam foam sclerotherapy), surgical approaches (ligation and stripping), and adjunctive procedures such as ambulatory phlebectomy; selection depends on anatomy, symptoms, and duplex criteria.

Evidence item	Key finding/value
VeClose trial – 3-month closure rates
VenaSeal (CAC) 99% vs RFA 96%
VeClose trial – 24-month closure rates
CAC 95.3% vs RFA 94.0%
VeClose trial – 36-month closure rates
CAC 94.4% vs RFA 91.9%
VeClose trial – 60-month freedom from recanalization (Kaplan–Meier)
CAC 91.4% vs RFA 85.2%
MOCA outcomes vs RFA/EVLA
MOCA inferior for GSV closure (lower odds vs RFA, CAC, EVLA); pooled short-term anatomic success ~91–92%; higher recanalization by 36 months (≈15% between 12–36 mo)
Varithena (PEM) FDA approval date
Approved Nov 25, 2013 for incompetent GSVs, accessory saphenous veins, visible varicosities
ClariVein (MOCA) FDA clearance date
ClariVein infusion catheter K071468 approval March 20, 2008
VenaSeal FDA PMA
PMA P140018 approval Feb 20, 2015 for permanent closure of superficial truncal veins
VenoValve evidence status
Very limited (11 subjects), investigational; not FDA approved
Meta-analysis findings (Kolluri 2020 ranking)
VenaSeal highest probability for anatomic success (p = .980); RFA ranked second

Limitations and recommendations

Limitations and recommendations: certainty of evidence is limited by short follow-up, small studies, and methodological limitations; further RCTs and longer follow-up are recommended.

ALL of the following

Definitions

Term	Definition
Accessory Vein
Accessory saphenous veins: venous segment ascending parallel to the GSV and located more superficially above the saphenous fascia; includes anterior/posterior GSV, circumflex veins, and vein of Giacomini
Axial Reflux
Axial reflux: uninterrupted retrograde venous flow from groin to upper calf for GSV; knee to ankle for SSV; retrograde flow between two measurements ≥5 cm apart for accessory veins
Duplex Ultrasonography
Noninvasive imaging combining B-mode and Doppler to assess blood flow and venous reflux
Endovenous Ablation
Minimally invasive procedure using heat (radiofrequency or laser) to seal damaged veins
Functional or Physical Impairment
Deviation from normal tissue/organ function resulting in significant limitation in physical tasks or daily activities
Moderate to Severe Pain
Per VCSS: Moderate = daily pain interfering with but not preventing activities; Severe = daily pain limiting most activities
Varicose Veins
Dilated subcutaneous tributaries ≥ 3 mm diameter (CEAP class C2)
CAC/CAE/VenaSeal
Cyanoacrylate closure/embolization of truncal veins using proprietary adhesive systems (e.g., VenaSeal) to occlude target veins
PEM/Varithena
Pharmaceutical-grade polidocanol endovenous microfoam sclerotherapy (Varithena) for incompetent GSVs, accessory veins, visible varicosities
MOCA
Mechanochemical ablation combining mechanical injury and chemical sclerosant to ablate veins (ClariVein)
RFA/EVLA
Thermal endovenous ablation techniques: radiofrequency ablation (RFA) and endovenous laser ablation (EVLA)
EVTA
Endovenous thermal ablation (e.g., EVLA, RFA)
GSV/SSV
GSV: Great saphenous vein; SSV: Small saphenous vein
UGFS
Ultrasound-guided foam sclerotherapy
Telangiectasias/Spider Veins
Dilated small superficial veins < 1 mm in diameter, predominantly in lower extremities
Tributary Vein
Small superficial veins in the legs running close to the skin within the superficial plane of the subcutaneous layer
Sclerotherapy
Injection of liquid or foam chemicals into the vein to create a plug that seals it shut (updated definition)

Revision History

2025-08-01Policy changeLatest

Effective 08/01/2025: Policy reorganized to add non-thermal modalities (cyanoacrylate-based adhesive and endovenous foam sclerotherapy) as accepted treatment options for GSV, SSV, and Accessory Veins when clinical criteria are met; clarified duplex ultrasound thresholds (≥500 ms reflux) apply to Accessory Veins and trunk veins; added requirement that perforator veins not be secondary to acute DVT; added reference to InterQual CP for ambulatory phlebectomy; removed CPT codes 37500 and 37799; updated FDA, evidence and references.

2025-08-01Policy changeLatest

Added explicit statement that ablation of incompetent perforator veins using endovenous foam sclerotherapy and/or cyanoacrylate-based adhesive is unproven and not medically necessary due to insufficient evidence of efficacy (per policy revision notes and coverage criteria).

Policy Summary

PayerUnitedHealthcare

PolicySurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins

Policy CodePolicy CS117.AB

Change TypeCoverage revisions and coding updates (material)

Effective Date08/01/2025

Next Review DateN/A

SourceLink

On This Page

Sclerotherapy for spider veins/telangiectasias (CPT 36468) is considered cosmetic and excluded from coverage; such treatments do not improve a Functional, Physical, or Physiological Impairment.

For non-telangiectasia sclerotherapy, CPT codes 36470 (single incompetent vein) and 36471 (multiple incompetent veins, same leg) are covered up to three sessions per leg within a rolling 12-month (365-day) period. A session is defined as one date of service for CPT 36470/36471.

If targeted treatment uses injection of non-compounded foam sclerosant with ultrasound compression maneuvers for an extremity truncal vein, follow AMA coding guidance and report CPT 36465 or 36466 as applicable.

Follow InterQual CP: Procedures, Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein for PA reviews

Billing Rule

Sclerotherapy coding and session limits

Coding and session limits for sclerotherapy must be followed. Use the listed CPT codes for billing and apply session caps and AMA guidance where specified.

Affected codes: 36465, 36466, 36468, 36470, 36471
CPT 36470 and 36471: covered up to 3 sessions per leg within a rolling 12‑month period (a session = one date of service). More than 3 sessions/leg/12 months is considered cosmetic and may be denied.
CPT 36465 and 36466: per AMA guidance, use these codes when injection of non‑compounded foam sclerosant into an extremity truncal vein is performed with ultrasound‑guided compression maneuvers to direct injectate dispersion.

Denial Risk

Exclusions for cosmetic treatments

Claims for treatment of spider veins/telangiectasias and procedures that only address cosmetic concerns may be denied. CPT 36468 and similar codes for telangiectasia/spider vein treatment are considered cosmetic and do not meet criteria for reconstruction or medical necessity. Document medical necessity carefully when treating reticular or telangiectatic veins; ablation or procedures performed solely for cosmetic improvement may be denied.

CPT 36468 (sclerotherapy for telangiectasias/spider veins) considered cosmetic — may be denied
Ablation of reticular/telangiectatic veins for cosmetic reasons may be denied

Documentation Required

Clinical selection documentation for CAC/CAE

Document clinical selection for chronic axial or accessory (CAC/CAE) venous disease using CEAP classification and objective duplex criteria. Include CEAP class (e.g., C2–C6 as applicable), duplex-proven reflux measurements, and any exclusions that affect candidacy.

Document CEAP clinical class in the medical record
Duplex evidence of reflux ≥ 0.5 seconds (500 ms) for superficial and accessory veins
Note exclusions as applicable: prior treatment of the Great Saphenous Vein (GSV) that alters treatment planning, active deep vein thrombosis (DVT) or pulmonary embolism (PE), and therapeutic anticoagulation that would affect procedural timing or eligibility

Denial Risk

Perforator vein adhesive/foam ablation not covered

Ablation of perforator veins using foam sclerosant or cyanoacrylate adhesive is considered unproven and not medically necessary. Such treatments may be denied; if these are performed in investigational or trial contexts, document informed consent that explains unproven status and rationale.

Ablation of perforator veins with foam or cyanoacrylate adhesive is unproven/not medically necessary and may be denied
If used in a trial or off‑label context, document informed consent explaining investigational status

Prior Authorization

Medical records may be required for review

Medical records and supporting documentation may be requested as part of prior authorization or claim review to determine whether policy criteria are met. Submission of records does not guarantee coverage — reviewers will assess compliance with clinical and documentation criteria.

Records may be requested to confirm duplex findings, CEAP class, symptoms (e.g., ulceration, bleeding, stasis dermatitis, pain), prior treatments, and contraindications
Providing requested records improves timeliness of review but does not imply approval

Billing Rule

Coding guidance for foam sclerosant injection

Follow AMA coding guidance when billing for foam sclerosant injections into truncal extremity veins. Use CPT codes 36465 and 36466 when non‑compounded foam sclerosant is injected into a truncal extremity vein with ultrasound‑guided compression maneuvers to direct dispersion of the injectate.

Use CPT 36465/36466 for non‑compounded foam sclerosant injections into truncal extremity veins with ultrasound‑guided compression maneuvers (per AMA)
Do not use 36465/36466 for treatments that meet cosmetic exclusion criteria (e.g., isolated telangiectasias)

Many studies are limited by lack of blinding, single-center design, nonrandomized cohorts, small sample sizes, and short follow-up; pooled analyses note limited long-term data beyond 24–60 months and loss to follow-up bias

Health technology assessments and systematic reviews conclude CAE/VenaSeal and PEM have potential but unproven long-term benefits; larger, well-designed RCTs with longer follow-up are needed to establish comparative effectiveness and durability

Evidence for CAE use in incompetent perforator veins is limited; further robust RCTs required

2025-08-01Policy changeLatest

Removed prior language that ligation, subfascial, endoscopic surgery for perforating veins was proven and medically necessary in certain circumstances; replaced prior statement that cyanoacrylate-based adhesive embolization was unproven with acceptance of cyanoacrylate for truncal veins when criteria are met, while excluding its use for perforator veins.

2025-08-01Policy changeLatest

Revised coverage criteria to state initial and subsequent treatment of GSV, SSV, and Accessory Veins with RFA, EVLA, stripping with ligation/excision, endovenous foam sclerotherapy, and/or cyanoacrylate-based adhesive are reconstructive and medically necessary when listed criteria (including vein diameter thresholds and reflux duration ≥ 500 ms on standing or reverse Trendelenburg duplex) are met.

2025-08-01Policy changeLatest

Clarified sclerotherapy coding guidance: per AMA guidance report CPT 36465 or 36466 when injection of non-compounded foam sclerosant with ultrasound-guided compression maneuvers is performed for truncal extremity veins; CPT 36468 is explicitly cosmetic for spider veins; CPT 36470 and 36471 covered up to three sessions per leg within a rolling 12-month period.

2025-08-01Policy changeLatest

Added administrative/operational clarifications: reference to InterQual CP for phlebectomy clinical criteria; updated Description of Services, Clinical Evidence, FDA and References sections; added statements that benefit coverage is determined by federal/state/contract requirements and medical records may be required for review.