ModifiedUnitedHealthcarePolicy CS117LA.T

Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins (Louisiana)

Governs medical necessity and coding for surgical and ablative treatments of venous insufficiency and varicose veins for UnitedHealthcare members in Louisiana.

Policy Summary

PayerUnitedHealthcare

PolicySurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins (Louisiana)

Policy CodePolicy CS117LA.T

Change TypeCriteria and coding revisionsmodality scope updated

Effective DateSep 1, 2025

Next Review Date

Key ActionObtain and document a standing or reverse Trendelenburg duplex ultrasound showing reflux duration (≥500 ms) and vein diameters to support prior authorization.

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 language indicating endovascular embolization of varicose veins using cyanoacrylate-based adhesive is unproven and not medically necessary for treating venous reflux.

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.

Broadened list of treatable veins: replaced 'principal tributaries' with 'Accessory Veins' in duplex criteria and expanded covered treatment modalities to include endovenous foam sclerotherapy and cyanoacrylate-based adhesive.

Added requirement that incompetent perforator veins be not secondary to acute deep vein thrombosis and specified duplex ultrasound position for perforator assessment.

Changed sclerotherapy coding and session coverage: CPT 36470 and 36471 covered up to three sessions per leg per year; CPT 36465/36466 guidance updated for truncal extremity veins.

Added definitions for Superficial Vein, Telangiectasias/Spider Veins, and Tributary Vein; removed several cosmetic/reconstructive definitions.

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.

3 mmGSV/SSV/accessory diameter threshold

500 msDuplex reflux duration threshold

3.5 mmPerforator diameter threshold (thermal)

3Max sclerotherapy sessions/leg/yr

2CPT codes removed

LAApplicable state

Coverage and Medical Necessity Criteria

Thermal and non-thermal ablation — main trunks

Covered when ALL of the following are met

Main criteria for GSV/SSV/Accessory vein ablation: Individual must have one of the listed Functional or Physical Impairments: skin ulceration; documented episode(s) of frank bleeding from the varicose vein due to erosion or trauma; documented superficial thrombophlebitis; documented venous stasis dermatitis causing functional or physical impairment; or moderate to severe pain causing functional or physical impairment. Vein diameter: GSV, SSV, or Accessory vein ≥ 3 mm measured immediately below the appropriate junction via duplex ultrasonography. Duplex ultrasound performed in the standing or reverse Trendelenburg position demonstrates reflux duration ≥ 500 milliseconds for the GSV, SSV, or Accessory veins.

GSV, SSV, and Accessory Vein treatment

Covered when ALL of the following are met for truncal vein (GSV/SSV/Accessory) treatments

Duplex evidence: Duplex ultrasound study performed in the standing or reverse Trendelenburg position showing duration of reflux >= 500 ms for the GSV, SSV, or Accessory veins.>= 500 ms

Treatment modalities: Initial and subsequent treatment of GSV, SSV, and Accessory veins with radiofrequency ablation, endovenous laser ablation, stripping with ligation and excision, endovenous foam sclerotherapy (pharmaceutical-grade), and/or cyanoacrylate-based adhesive are considered reconstructive and medically necessary when all listed criteria are met.

Perforator vein thermal ablation

Covered when ALL of the following are met

Perforator vein thermal ablation: Evidence of perforator venous insufficiency measured by a recent duplex ultrasound study performed in the standing or reverse Trendelenburg position; perforator vein diameter ≥ 3.5 mm; perforator reflux >= 500 ms; perforator lies beneath a healed or active venous stasis ulcer; and the perforator incompetence is not secondary to acute deep vein thrombosis.

Incompetent Perforator Vein ablation (RFA/EVLA)

Covered when ALL of the following are met for incompetent perforator vein ablation (radiofrequency or endovenous laser):

Duplex evidence position: Evidence of perforator venous insufficiency measured by recent duplex ultrasound study performed in the standing or reverse Trendelenburg position.

Reflux duration: Perforating vein reflux of 500 ms or greater.>= 500 ms

DVT exclusion: The incompetent perforator veins are not secondary to acute deep vein thrombosis.

Ligation to prevent clot propagation

Covered when ALL of the following are met

Ligation for ascending superficial thrombophlebitis: 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.

Medical necessity for therapeutic procedures

Covered when ALL of the following are met (inferred from evidence and exclusions):

General medical necessity

Accepted modalities: Endovenous thermal ablation (EVLA/RFA), endovenous adhesive embolization (cyanoacrylate), mechanochemical ablation, pharmaceutical endovenous microfoam (PEM), surgical ligation/stripping, and phlebectomy are described as therapeutic options.
Choice informed by clinical evidence in document

Coverage criteria aligned to RCT populations

Covered when ALL of the following trial-based clinical criteria are met (evidence-derived):

Primary coverage criteria for CAC/RFA/EVLA: 1) Symptomatic chronic venous insufficiency with CEAP clinical class C2–C5; 2) Duplex ultrasound documented GSV incompetence with reflux duration >= 0.5 seconds; 3) Target GSV suitable (aneurysm <= 12 mm in trials); 4) No prior treatment of the target GSV in the same limb as in key RCTs; 5) Patient factors consistent with trial populations (e.g., BMI <= 35, no active anticoagulation or uncontrolled hypercoagulable disorder).

Derived from inclusion/exclusion criteria and endpoints in randomized trials (VeClose, Alhewy et al.).

Truncal vein treatment (CAE/PEM)

Covered when ALL of the following are met (evidence supports use for truncal veins):

Truncal vein CAE/PEM coverage evidence: Randomized trials and multicenter series report high technical closure rates (often >90% at 12–36 months) and sustained symptom and quality-of-life improvements for treatment of incompetent great saphenous vein (GSV) and other truncal veins with cyanoacrylate adhesive (CAE) or pharmaceutical-grade polidocanol microfoam (PEM); thus use for symptomatic truncal vein reflux with appropriate diagnostic duplex is supported by the cited evidence.

Supported by VeClose RCT, WAVES series, and PEM randomized trials.

Perforator vein treatment (CAE/foam)

Not sufficiently supported / investigational when used for isolated perforator vein incompetence:

Perforator vein CAE or foam sclerotherapy: Peer-reviewed evidence evaluating cyanoacrylate adhesive or endovenous foam sclerotherapy for isolated incompetent perforator veins is limited and does not demonstrate clear benefit compared with established therapies; available studies are small, retrospective, or nonrandomized and lack long-term outcomes.

Further robust RCTs and long-term data are needed before routine coverage.

Evidence-influenced coverage positions (narrative)

Guidance and evidence summaries influencing coverage stance for non-thermal endovenous procedures:

EVTA first-line: For patients with GSV and SSV incompetence, endovenous thermal ablation (EVTA) is recommended as the first-choice treatment per ESVS and multiple guideline summaries.

MOCA evidence: MOCA demonstrates lower anatomical occlusion at one year compared with EVTA in some meta-analyses and RCTs; non-thermal techniques may have less peri-procedural pain and lower nerve injury risk but mid-term durability is uncertain.

Foam sclerotherapy for perforator veins: Evidence for endovenous foam sclerotherapy to treat incompetent perforator veins is limited and does not show clear benefit over established therapies; additional RCTs are needed.

Cyanoacrylate glue (CAE): Cyanoacrylate adhesive closure shows comparable short- to mid-term results to RFA/EVLA in randomized trials with favorable pain and nerve injury profiles; NICE supports its use with clinical governance and training requirements.

Guideline-based coverage considerations

Guideline recommendations summarized (SVS/AVF/AVLS/SIR, AUC, and related guidance).

Axial truncal reflux with symptoms: Ablation of refluxing superficial truncal veins (GSV, SSV, AAGSV, PAGSV) is recommended for symptomatic patients with axial reflux (CEAP C2–C6), using endovenous ablation when available; alternatives include high ligation and stripping when endovenous options are unsuitable.CEAP C2–C6; reflux >500 ms

Choice of modality: Both thermal (EVLA, RFA) and nonthermal (cyanoacrylate glue, MOCA) ablation may be used depending on physician expertise and patient preference; for long-term outcome priority EVLA/RFA/high ligation & stripping may be preferred over physician-compounded UGFS.

Treatment of varicose tributaries: For symptomatic tributaries and telangiectasias, sclerotherapy (liquid or foam) or miniphlebectomy is recommended; concomitant phlebectomy or UGFS is recommended with trunk ablation when associated varicosities exist.

Unproven / Not Medically Necessary

Not medically necessary / unproven procedures

Unproven treatments: Ablation of perforator veins using endovenous foam sclerotherapy and/or cyanoacrylate-based adhesive; endovenous mechanochemical ablation (MOCA) of varicose veins; porcine bioprosthetic valve (VenoValve) implantation into the femoral vein; certain ligation procedures as stand-alone treatments for venous reflux (GSV, SSV, Accessory veins); and ligation used as an adjunct to thermal ablation where evidence is insufficient.

CPT code 36468 (sclerotherapy for spider veins/telangiectasia) is considered cosmetic and excluded from coverage. For non-telangiectatic sclerotherapy (codes 36470/36471), coverage is limited to a maximum of three sessions per leg within a rolling 12‑month period; more than three sessions per leg in a year is considered cosmetic and excluded. A single session is defined as one date of service during which CPT 36470 or 36471 is performed.

Treatment of spider veins/telangiectasias and any cosmetic sclerotherapy are excluded from coverage as cosmetic procedures. CPT codes describing injection(s) for telangiectasias (for example, 36468) are explicitly identified as non‑covered because these interventions do not address a Functional, Physical, or Physiological Impairment.

Endovenous ablation of reticular or telangiectatic veins is not considered reconstructive or medically necessary and is excluded from coverage. Ablation targeted to these small superficial networks does not meet criteria for treatment of symptomatic venous reflux.

Characteristics commonly used as exclusionary in randomized trials — and that may affect coverage consideration — include active CEAP class 6 (ulceration), prior treatment of the target GSV, target GSV aneurysm > 12 mm, body mass index > 35, current use of anticoagulation or ongoing treatment for a hypercoagulable disorder, and patterns of reflux (for example isolated SSV or AAGSV) that were excluded from key studies. Presence of these features may render a request inconsistent with trial populations used to demonstrate benefit.

Evidence for endovascular embolization using cyanoacrylate-based adhesive and for endovenous foam sclerotherapy when used to treat isolated incompetent perforator veins is limited. Peer‑reviewed studies are small, often retrospective or nonrandomized, and lack long‑term outcomes; therefore these approaches for isolated perforator incompetence are considered investigational or not sufficiently supported for routine coverage.

The VenoValve porcine bioprosthetic venous valve remains investigational. Published human data are limited to very small early series and pilot reports; the device is not yet FDA‑approved and current evidence is insufficient to support routine coverage outside of clinical trials.

NICE advises that cyanoacrylate glue occlusion and mechanochemical ablation should only be used where standard arrangements for clinical governance, informed consent, and audit are in place. Clinicians should have appropriate training in venous ultrasound and collect longer‑term follow‑up data as part of routine governance.

The policy now includes an explicit noncoverage statement: ablation of incompetent perforator veins using endovenous foam sclerotherapy and/or cyanoacrylate-based adhesive is considered unproven and not medically necessary due to insufficient evidence of efficacy when proposed as primary therapy for isolated perforator incompetence.

Procedures identified as having limited or insufficient evidence include mechanochemical ablation (MOCA), porcine bioprosthetic valve implantation (VenoValve), and several ligation procedures when used as stand‑alone treatments for venous reflux. These procedures are considered investigational or not medically necessary unless clear supporting evidence or enrollment in clinical research is documented.

Cosmetic sclerotherapy is explicitly excluded from coverage. In particular, injection(s) of sclerosant for telangiectasias/spider veins (CPT 36468) are classified as cosmetic and non‑covered.

Use of cyanoacrylate products or systems that are not FDA‑approved/cleared and that are being used outside of formal clinical research is considered unproven. Providers should document device identity and relevant regulatory status when requesting consideration; non‑approved systems used outside research settings are not supported by the evidence base.

The literature evaluating endovenous foam sclerotherapy and cyanoacrylate adhesive specifically for perforator veins is limited, often retrospective, and lacks robust randomized and long‑term outcomes. Given this insufficient peer‑reviewed evidence, these techniques for isolated perforator incompetence do not meet criteria for routine coverage.

Some non‑thermal modalities, including endovenous foam sclerotherapy for perforator veins and MOCA, are supported only by limited or low‑quality evidence. Consequently, these interventions may be considered investigational and not medically necessary when proposed as substitutes for established endovenous thermal ablation without demonstrable long‑term efficacy.

NICE recommends offering ultrasound‑guided foam sclerotherapy (UGFS) when endovenous ablation is unsuitable. This guidance supports UGFS as an alternative for selected patients, but does not extend to routine use of foam or adhesive specifically for isolated perforator incompetence without stronger evidence.

Policy text that previously described cyanoacrylate‑based adhesive as broadly unproven was revised. The historical language was operationally removed and replaced with more focused statements clarifying that CAE is supported for truncal vein indications in evidence‑aligned scenarios while remaining unproven/non‑covered for isolated perforator vein ablation unless supported by robust data or research enrollment.

Procedure and Device Coding

Applicable procedure CPT codesCPT

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 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; subsequent vein(s) 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.

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Listed CPT Codes (procedures)CPT

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.
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.
37765	Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions.
37766	Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions.
37780	Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure).
37785	Ligation, division, and/or excision of varicose vein cluster(s), 1 leg.

No explicit codes listed in this excerptmixed

No codes listed

FDA device identifiers referencedmixed

K071468	ClariVein infusion catheter – FDA 510(k) number.
P140018	VenaSeal Closure System – FDA PMA number.

Sclerotherapy and related CPT codesCPT

36465	Injection of non-compounded foam sclerosant into targeted extremity truncal vein (per AMA guidance).
36466	Second or subsequent injection of non-compounded foam sclerosant into targeted extremity truncal vein (per AMA guidance).
36468	Sclerosant injection for telangiectasia/spider veins (considered cosmetic for Spider Veins/ Telangiectasias).
36470	Sclerotherapy (non-truncal, non-telangiectasia) — covered up to three sessions per leg per year.
36471	Sclerotherapy (non-truncal, non-telangiectasia) — covered up to three sessions per leg per year.

Removed CPT CodesCPTNot Covered

37500	Removed from applicable codes list
37799	Removed from applicable codes list

Reflux duration thresholds — Superficial and perforator veins; Deep veins

Superficial and perforator veins reflux durationGreater than or equal to 500 milliseconds (0.5 sec)

Deep veins reflux durationGreater than or equal to 1.0 second

Duplex position for measurementStudy performed in standing or reverse Trendelenburg position

Vein diameter thresholds

GSV / SSV / Accessory vein diameterGreater than or equal to 3.0 millimeters

Perforator vein diameter for thermal ablation

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required — Evidence-Based Eligibility Documentation

Prior authorization may be required. Requests should include documentation that the individual meets evidence-based eligibility criteria: symptomatic CEAP clinical class C2–C5 disease (or clinical findings listed in the policy) and duplex-ultrasound–proven truncal reflux (GSV, SSV, or accessory veins) with measured reflux duration ≥ 500 ms and vein diameter ≥ 3.0 mm for truncal veins (≥ 3.5 mm for perforator veins when applicable). For perforator vein ablation, documentation must show the perforator lies beneath a healed or active venous stasis ulcer when applicable and is not secondary to acute deep vein thrombosis.

Provide preoperative duplex ultrasound performed in standing or reverse Trendelenburg position with measured reflux duration (ms) and vein diameters (mm).
Document CEAP clinical class and specific symptoms (e.g., ulceration, bleeding, venous stasis dermatitis, symptomatic pain interfering with function).
For perforator procedures, include duplex evidence of perforator reflux ≥ 500 ms and diameter ≥ 3.5 mm and demonstration that perforator insufficiency is not secondary to acute DVT.

Prior Authorization

Prior Authorization — Evidence Support and Device Documentation

Definitions and Terminology

Duplex Ultrasonography

Duplex Ultrasonography — definitionNoninvasive imaging using B-mode and Doppler to assess blood flow and venous anatomy; used in standing or reverse Trendelenburg to measure reflux and vein diameter

PurposeProvides anatomic mapping and hemodynamic data (reflux duration, vein diameter) to support treatment decisions

Measurement positionStanding or reverse Trendelenburg position required for policy duplex documentation

Varicose Veins / Venous Reflux

Varicose veins definitionDilated subcutaneous tributaries ≥ 3 mm in diameter (CEAP clinical class C2)

Venous reflux abnormal thresholdsSuperficial and perforator veins: ≥ 0.5 sec (500 ms); deep veins: ≥ 1 sec

Clinical Background and Evidence Summary

Varicose veins result from valvular incompetence leading to reflux and venous dilation. Duplex ultrasonography performed in the standing or reverse Trendelenburg position is the diagnostic gold standard to document anatomy, measure vein diameter, and quantify reflux duration; these duplex parameters are required to support procedural indications.

Policy Revision History

2025-09-01policy_revision

Removed prior language that deemed certain ligation/subfascial endoscopic procedures and cyanoacrylate embolization as proven; 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.

2025-09-01policy_revision

Replaced wording for truncal vein treatments to expand covered modalities and updated vein terminology (replaced 'principal tributaries' with 'Accessory Veins') and standardized duplex criteria language.

2025-09-01

Policy Summary

PayerUnitedHealthcare

PolicySurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins (Louisiana)

Policy CodePolicy CS117LA.T

Change TypeCriteria and coding revisionsmodality scope updated

Effective DateSep 1, 2025

Next Review Date

Key ActionObtain and document a standing or reverse Trendelenburg duplex ultrasound showing reflux duration (≥500 ms) and vein diameters to support prior authorization.

SourceLink

On This Page

VenoValve evidence is very limited (small pilot/first-in-human series); the device remains investigational and not FDA-approved for routine use.

Perforator and ulcer-related management: In patients with venous leg ulcers (C6) or healed ulcers (C5) with axial reflux to the ulcer bed and pathologic perforators (reflux >500 ms and diameter >= 3.5 mm), ablation of incompetent superficial veins and perforators in addition to compression is suggested to aid healing and prevent recurrence.CEAP C5–C6; perforator criteria as above

Use of truncal diameter: Truncal vein diameter should not be the sole determinant to select patients for venous ablation in symptomatic C2 disease.

Greater than or equal to 3.5 millimeters

CEAP C2 tributary threshold (context)Varicose tributaries defined as ≥ 3 mm (CEAP C2)

Vein diameter (CEAP C2 threshold)

CEAP clinical class C2 diameter thresholdGreater than 3 millimeters

Definition sourceCEAP classification in policy (C2 = varicose veins)

Duplex use for measurementMeasured by duplex ultrasound in standing or reverse Trendelenburg position

Duplex reflux duration threshold

Duplex reflux duration threshold for coverage and trials>= 0.5 seconds (500 ms)

Measurement positioningDuplex performed standing or in reverse Trendelenburg

Applies toGSV, SSV, Accessory and relevant perforator veins per policy and guideline definitions

Target GSV aneurysm size exclusion

Target GSV aneurysm size exclusion> 12 millimeters (aneurysm >12 mm excluded from trial-like eligibility)

Source contextListed as an exclusion in randomized trial eligibility and policy exclusions

Impact on coverage considerationPresence of aneurysm >12 mm may affect eligibility for GSV procedures

BMI exclusion in trials

BMI exclusion used in trials> 35 (BMI over 35 excluded in key RCTs)

Trial-based eligibility noteBMI >35 listed among trial exclusion criteria that inform coverage considerations

Documentation implicationPatient BMI may be referenced when aligning requests to trial populations

Vein diameter treated in WAVES study

Maximum vein diameter treated in WAVES studyUp to 20 millimeters

Veins includedGSV, SSV, and accessory saphenous veins up to 20 mm were treated in WAVES case series

Follow-up timingShort-term closure assessed at 7 days and 1 month in WAVES report

duplex reflux duration

Duplex reflux duration (policy/guideline)> 500 milliseconds

Applies toSuperficial truncal and perforating veins per SVS/AVF guidance and policy definitions

Measurement positionStanding or reverse Trendelenburg duplex study

pathologic perforator diameter

Pathologic perforator diameter definition>= 3.5 millimeters (perforator diameter)

Associated reflux durationOutward flow duration ≥ 500 ms constitutes pathologic perforator with diameter threshold

Clinical contextUsed when considering perforator ablation in patients with ulcers or CEAP C2–C6 disease

Duplex reflux duration

Duplex reflux duration threshold (policy phrasing)>= 500 milliseconds (ms)

Applies toGSV, SSV, Accessory and perforating veins per policy coverage criteria

Documentation requirementReport reflux duration in standing or reverse Trendelenburg duplex study

Procedure codes referenced

Procedure codes and prior authorizationPrior authorization may be required per contractual rules; applicable procedure codes are listed in the policy's code section for reference

Provider actionRefer to the policy 'Applicable Codes' section when submitting authorization requests

Coverage noteListing of a code does not imply coverage or guarantee payment; follow federal/state/contractual rules

Prior authorization submissions should reference device- or technique-specific approvals and clinical evidence when applicable. For requests involving proprietary devices or modalities (e.g., VenaSeal, Varithena, ClariVein, other cyanoacrylate or proprietary foam systems), attach device labeling/FDA approval (PMA/510(k)) or manufacturer instructions for use and pertinent peer-reviewed evidence supporting the requested procedure.

List the device name, model, and FDA indication (if applicable).
Attach relevant clinical trial identifiers/publications and summaries supporting use for the indicated vein/clinical scenario.
If requesting CAE or proprietary foam for perforator veins or other indications with limited evidence, include rationale and supporting literature.
When using MOCA or other limited-evidence non-thermal modalities, include documentation of clinical governance and physician training.
Note: FDA approval alone does not guarantee coverage; clinical context and plan contract terms apply.

Denial Risk

Trial-Based Exclusion Characteristics That May Impact Coverage

Requests may be denied when trial-based or exclusion characteristics are present. Prior treatment history and specified exclusions from key trials should be clearly documented and considered in authorization decisions.

Document prior treatment of the target truncal vein (prior GSV treatment may affect eligibility or require additional justification).
Disclose history of DVT or PE, anticoagulation status, active hypercoagulable disorder, or current anticoagulant use.
Report aneurysm of target GSV > 12 mm, BMI > 35, or severe peripheral arterial disease when present (these were exclusions in pivotal trials).
If CEAP class 6 (active ulcer) or other trial-excluded clinical states apply, provide supporting clinical rationale for the requested procedure.

Documentation Required

Consent, Clinical Governance, and Audit Documentation

Follow institutional and national guidance for consent, clinical governance, and audit. For certain modalities (CAE, MOCA), NICE and specialty societies recommend documenting informed consent, operator training, local governance arrangements, and participation in audit or data collection.

Document that the treating clinician has appropriate training and experience (including venous duplex ultrasound competency).
Obtain and retain written informed consent that discusses alternative therapies, risks (including phlebitis, pigmentation, recanalization), and device-specific complications.
Indicate whether the site participates in clinical audit or registry reporting and retain records of local outcome monitoring.
For non-thermal/non-sclerosant techniques, document clinical governance and post-procedure follow-up plans.

Documentation Required

Required Duplex Ultrasound Documentation

Duplex ultrasonography documentation is required and must be performed in the standing or reverse Trendelenburg position. Reports must quantify vein diameters and reflux duration and identify the anatomic segments treated.

Include study position (standing or reverse Trendelenburg) and measured reflux duration in milliseconds (target threshold ≥ 500 ms).
Report vein diameters at the appropriate anatomic locations (GSV proximal thigh immediately below SFJ, SSV/AAV immediately below junction, perforator diameter when applicable).
Specify which veins are incompetent and planned to be treated (GSV, SSV, accessory veins, perforators) and provide preoperative mapping.
Attach duplex images or interpretive report summaries showing reflux waveforms and measurements.

Note

Consideration of Conservative/Medical Therapy Prior to Procedural Interventions

Conservative or medical therapy should be considered and documented prior to procedural interventions when clinically appropriate. Documentation of failed or intolerant conservative measures can support medical necessity for procedural treatment.

Document trials of compression therapy (type/duration) and conservative measures and response.
When applicable, document use or trial of medical therapy (e.g., anticoagulation for superficial thrombophlebitis) and reasons for failure or intolerance.
For superficial thrombophlebitis or SVT, document rationale for surgical or interventional treatment if medical therapy was inadequate or contraindicated.
Include objective functional impact (pain severity, activity limitation, ulcer healing status) to support escalation to procedural therapy.

Clinical relevanceCriteria used to determine medical necessity for procedural treatment of symptomatic varicosities

CEAP clinical class C2

CEAP class C2 — varicose vein diameterVeins with diameter greater than 3 millimeters

CEAP usageCEAP clinical class used to stratify disease severity for treatment decisions

Measurement methodDiameter measured by duplex ultrasound

Endovascular cyanoacrylate embolization

Endovascular cyanoacrylate embolization (CAC) definitionA non-thermal, non-sclerosant procedure using cyanoacrylate adhesive (e.g., VenaSeal) to close truncal superficial veins without tumescent anesthesia

Typical usesUsed to occlude incompetent GSV, SSV, and accessory veins as an alternative to thermal ablation

Regulatory referenceVenaSeal Closure System has PMA (P140018) cited in policy FDA section

Mechanochemical ablation (ClariVein)

Mechanochemical ablation (MOCA) definitionCatheter-based technique combining mechanical endothelial damage via a rotating wire with local sclerosant infusion to induce vein sclerosis and occlusion (e.g., ClariVein)

MechanismMechanical disruption plus chemical sclerosant delivered via catheter; non-thermal, non-tumescent

Evidence noteMOCA shows lower anatomical occlusion at one year compared with EVTA in some analyses

Recanalization / REVAS

Recanalization / REVAS definitionRecanalization is reopening of a treated vein and is a common cause of recurrent varicose veins after endovenous ablation (REVAS)

Clinical impactRecanalization and development of new incompetent tributaries are leading causes of recurrence after ablation

ReportingRecurrence rates vary by follow-up duration and technique; document in follow-up imaging

Cyanoacrylate closure (CAC)

Cyanoacrylate closure (CAC) summaryEndovascular embolization using cyanoacrylate-based adhesive (e.g., VenaSeal) to occlude target truncal veins without tumescent anesthesia

EvidenceRCTs (VeClose, Alhewy) report high short- and mid-term closure rates and favorable patient recovery profiles

ConsiderationsRequires clinical governance; device-specific documentation may be requested for prior authorization

CAC/CAE

CAE / CAC definitionEndovascular embolization using cyanoacrylate-based adhesive (e.g., VenaSeal) to occlude incompetent truncal veins without tumescent anesthesia

Non-thermal characteristicDoes not require tumescent anesthesia and is considered non-thermal, non-sclerosant

Clinical outcomesRandomized trials show comparable closure rates to RFA/EVLA at short- to mid-term follow-up

PEM

PEM definitionPolidocanol 1% endovenous microfoam (pharmaceutical-grade foam, e.g., Varithena) used to sclerose incompetent veins; distinct from physician-compounded foam

IndicationUltrasound-guided foam sclerotherapy for truncal and tributary varicosities

EvidenceRCTs and meta-analyses show symptom and occlusion benefits versus placebo and comparable results to EVTA in some analyses

MOCA (mechanochemical ablation)

MOCA definitionA non-thermal, non-tumescent technique combining mechanical disruption of the endothelium with infusion of sclerosant (often via ClariVein) to close incompetent saphenous veins

CharacteristicsProduces mechanical endothelial injury plus chemical sclerosant; potential advantages include less post-procedure pain and low nerve injury risk

Evidence noteAnatomical occlusion rates are variable; some RCT meta-analyses show lower occlusion versus EVTA at 1 year

VenoValve

VenoValve definitionPorcine bioprosthetic venous valve investigational device intended for surgical implantation into the femoral vein to treat deep vein reflux

Regulatory statusNot FDA-approved at time of report; early human data limited to small series

EvidenceAvailable evidence limited to small pilot/first-in-human studies; considered investigational

Reflux (duplex ultrasound)

Reflux (duplex ultrasound) definitionReflux defined as reversed flow duration > 500 milliseconds in superficial truncal veins

Veins includedGSV, SSV, AAGSV, PAGSV and relevant perforators and tibial/deep femoral veins per guidelines

Measurement positionStanding or reverse Trendelenburg duplex ultrasound

Pathologic perforating vein

Pathologic perforating vein criteriaPerforator with outward flow duration ≥ 500 ms and diameter ≥ 3.5 mm on duplex ultrasound

Clinical applicabilityUsed to identify perforators that may warrant ablation in the context of ulcer or symptomatic disease

Measurement contextDuplex performed standing or reverse Trendelenburg

Accessory Vein

Accessory Vein — policy definition updateAccessory saphenous veins are defined and included among treatable truncal veins (policy definitions revised)

ExamplesIncludes anterior/posterior accessory GSVs and Giacomini vein variants

ImplicationAccessory veins included in duplex and diameter/reflux criteria for coverage

Telangiectasias/Spider Veins

Telangiectasias/Spider Veins definitionDilated small superficial veins measuring less than 1 millimeter in diameter; distinguished from truncal varicosities for cosmetic considerations

Coverage statusTreatment for telangiectasias/spider veins (e.g., CPT 36468) is considered cosmetic and excluded

Coding implicationDifferent CPT guidance applies versus truncal vein sclerotherapy

Revised perforator vein criteria to require duplex testing in standing or reverse Trendelenburg position, specified reflux wording as '500 ms or greater', and added requirement that incompetent perforator veins not be secondary to acute DVT.

2025-09-01coding_updateLatest

Updated definitions and coding: added definitions (Superficial Vein, Telangiectasias/Spider Veins, Tributary Vein), removed CPT codes 37500 and 37799, and clarified sclerotherapy CPT guidance (coverage limits for 36470/36471; instruction to use 36465/36466 for truncal foam per AMA guidance).