ModifiedUnitedHealthcarePolicy CS117.AB

Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins

Medical policy governing indications, coding, and coverage stance for surgical and ablative treatments of venous insufficiency and varicose veins for UnitedHealthcare; specifies clinical criteria, definitions, and coding guidance relevant to providers.

Policy Summary

PayerUnitedHealthcare

PolicySurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins

Policy CodePolicy CS117.AB

Change TypeCriteria and coding revisionsmaterial coverage updates

Effective Date08/01/2025

Next Review DateN/A

Key ActionWhen requesting prior authorization, provide standing or reverse Trendelenburg duplex ultrasound documenting vein diameter and reflux (>=500 ms) and clinical impairment to support coverage.

SourceLink

POLICY UPDATE CHANGES

Replaced coverage language to include initial and subsequent treatment of GSV, SSV, and Accessory Veins with radiofrequency ablation, endovenous laser ablation, stripping with ligation and excision, endovenous foam sclerotherapy, and/or cyanoacrylate-based adhesive as reconstructive and medically necessary when all listed criteria are met.

Added language 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.

Revised duplex ultrasound criteria text to reference Accessory Veins and clarified reflux thresholds (>= 500 ms) for GSV, SSV, Accessory and perforating veins; required standing or reverse Trendelenburg duplex studies.

Updated coding notations: removed CPT 37500 and 37799; clarified use of CPT 36465/36466 for extremity truncal vein foam sclerosant injections per AMA guidance; removed notation for 37241; changed coverage listing for sclerosant and telangiectasia codes (36468 cosmetic; 36470/36471 covered for non-truncal non-telangiectasia up to three sessions per leg per year).

Added definition entries for Superficial Vein, Telangiectasias/Spider Veins, and Tributary Vein; removed definitions for Cosmetic Procedures and Reconstructive Procedures.

>=3 mmVein diameter threshold (GSV/SSV/Accessory)

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.

>=500 msDuplex reflux duration threshold

3.5 mmPerforator diameter threshold

95.3% vs 94.0%24-mo GSV closure (CAC vs RFA)

91.4% vs 85.2%60-mo freedom from recanalization (CAC vs RFA)

Coverage Criteria — Indications and Limitations

Covered: Endovenous Ablation, Stripping, Foam Sclerotherapy, Cyanoacrylate

Covered when ALL of the following are met:

Overall: Member has one of the listed Functional or Physical Impairments AND vein size and duplex reflux criteria are met

Functional or Physical Impairments listed below

Functional or Physical Impairment: One of: skin ulceration; documented frank bleeding of the varicose vein due to erosion or trauma; documented superficial thrombophlebitis; documented venous stasis dermatitis causing functional or physical impairment; moderate to severe pain causing functional or physical impairment

From policy criteria

Vein size and reflux: GSV >= 3 mm measured at the proximal thigh immediately below the saphenofemoral junction; SSV or Accessory veins >= 3 mm measured immediately below the appropriate junction; duplex ultrasound performed in standing or reverse Trendelenburg shows reflux >= 500 ms for the GSV, SSV, or Accessory veinsGSV/SSV/Accessory >=3 mm; reflux >=500 ms

Duplex interpretations describing moderate to severe reflux acceptable

Covered: Perforator Ablation (RFA or EVLA)

Ablation of incompetent perforator veins is considered reconstructive and medically necessary when ALL of the following are met:

Perforator ablation criteria: Recent duplex ultrasound in standing or reverse Trendelenburg documents perforator venous insufficiency; perforator vein diameter >= 3.5 mm; perforator reflux duration >= 500 ms; the perforator lies beneath a healed or active venous stasis ulcer; condition is not secondary to acute deep vein thrombosisperforator >=3.5 mm; reflux >=500 ms

Endovenous RFA or EVLA acceptable; endovenous foam sclerotherapy or cyanoacrylate for perforators is unproven and not medically necessary

Surgical Ligation: Indicated vs Not Medically Necessary

Specific surgical ligation positions:

Indicated (medically necessary): Ligation at the saphenofemoral junction as a stand‑alone procedure 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

Proven and medically necessary per policy

Not medically necessary / Unproven: 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 SFJ when used as an adjunct to RFA or EVLA of main saphenous veins

These ligation indications are unproven and not medically necessary

Ambulatory Phlebectomy Coverage

Ambulatory phlebectomy coverage statement:

Ambulatory phlebectomy: Proven and medically necessary in certain circumstances; medical necessity clinical coverage criteria are determined by InterQual ® Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein

Refer to InterQual criteria as specified in policy

Not Medically Necessary: Other Procedures

The following procedures are considered unproven and not medically necessary:

Unproven procedures: Endovenous mechanochemical ablation (MOCA) of varicose veins; porcine bioprosthetic valve implantation (e.g., VenoValve) into the femoral vein for treatment of deep vein reflux

Insufficient evidence of efficacy

Excluded services

Coverage limitations and exclusions:

Cosmetic exclusions: Treatments for spider veins and/or telangiectasias are considered cosmetic and excluded from coverage; cosmetic sclerotherapy is excluded (CPT 36468).

From policy exclusions

Non-reconstructive exclusions: Endovenous ablation (RFA and/or EVLA) of reticular or telangiectatic veins is not reconstructive and not medically necessary and therefore excluded from coverage.

From policy exclusions

Trial-based coverage/assessment criteria

Trials generally considered CAC noninferior when ALL of the following were met:

Trial-based eligibility: Symptomatic GSV incompetence (commonly CEAP C2–C5) with GSV reflux >= 0.5 seconds on duplex ultrasound; target vein diameter within trial limits (no aneurysm >12 mm); and absence of exclusion conditions such as prior GSV treatment, symptomatic peripheral arterial disease, history of DVT/PE, BMI >35, active anticoagulation, or sensitivity to cyanoacrylate adhesivessee trial criteria

Derived from VeClose and similar RCT eligibility/exclusion lists

Primary outcome/endpoint: Anatomic success defined as complete closure of the target vein on duplex ultrasound at three months (primary endpoint in pivotal RCTs), with follow‑up visits extending to 24–60 months used for longer‑term assessmentclosure at 3 months

Used as primary noninferiority endpoint in VeClose and related studies

CAE/CAC evidence summary

Evidence-summary based criteria and comparative findings for cyanoacrylate adhesive:

CAE/CAC evidence summary: CAE/CAC demonstrates high vein closure rates and sustained symptom and QOL improvement in single‑arm cohorts and randomized trials (e.g., VeClose, Proebstle, WAVES) with long‑term freedom from recanalization reported in some studies comparable to RFA; study limitations include small samples, limited randomized head‑to‑head data and potential follow‑up bias for long‑term outcomes

Applicable for GSV/SSV/accessory truncal vein incompetence; evidence for perforator veins is limited

PEM evidence summary

PEM (polidocanol microfoam) evidence and limitations:

PEM (Varithena): Randomized, placebo‑controlled trials show PEM improves symptoms, appearance, and clinician‑assessed outcomes versus placebo; network meta‑analysis found PEM not statistically different from EVTA for vein closure but data are limited for long‑term comparative outcomes versus thermal ablation

May be considered for symptomatic visible varicosities; longer‑term comparative data versus EVTA remain limited

MOCA evidence summary

MOCA comparative effectiveness summary:

MOCA: Systematic reviews and meta‑analyses demonstrate MOCA has lower GSV occlusion and less VCSS improvement compared with RFA, EVLA, and CAC in several analyses; MOCA may have a favorable pain or paresthesia profile in some comparisons but overall mid‑term effectiveness and long‑term durability are limited

Considered less effective for primary GSV closure compared to thermal and some nonthermal alternatives

Coverage considerations

Considerations when selecting MOCA or VenoValve:

Preferred first-line treatments: EVTA (EVLA or RFA) is recommended as first‑choice treatment for GSV and SSV incompetence in most patients

Supported by ESVS and other society guidelines

When non‑thermal methods may be considered: Non‑thermal methods (MOCA, cyanoacrylate) may be considered when non‑thermal technique is preferred or anatomy/clinical factors preclude thermal EVTA

Guideline‑supported option in select circumstances

MOCA evidence limitations: MOCA has lower anatomical occlusion rates at one year compared with EVTA in pooled RCTs and meta‑analyses; long‑term durability data are limited

May influence coverage preference toward established EVTA

VenoValve status:

Guideline treatment criteria

Guideline and appropriate‑use recommendations relevant to treatment selection:

Axial truncal reflux treatment: For symptomatic axial reflux of the GSV or SSV, endovenous ablation (thermal or nonthermal) from groin to below knee (GSV) or knee to upper/mid‑calf (SSV) is recommended; EVTA is preferred over high ligation and stripping when availableCEAP symptomatic (C2‑C6)

Grade 1 recommendation; evidence B for GSV, C for SSV

Accessory saphenous veins: For symptomatic axial reflux in accessory saphenous veins, thermal or nonthermal ablation is suggested; if endovenous ablation is not available or anatomy precludes it, ligation and stripping with adjunctive phlebectomy is suggestedSymptomatic varicose veins

Grade 2 recommendation; evidence C

Venous leg ulcers and perforators: For venous leg ulcers (C6) with incompetent superficial veins and pathological perforators communicating with the ulcer bed, ablation of both incompetent superficial veins and perforators plus compression is suggested to aid healing and prevent recurrence

GSV, SSV, and Accessory Veins — Medically Necessary when all criteria met

Revised key coverage position for truncal veins:

GSV/SSV/Accessory Veins treatment: Initial and subsequent treatment of the GSV, SSV, and Accessory Veins with RFA, EVLA, stripping with ligation and excision, endovenous foam sclerotherapy, and/or cyanoacrylate‑based adhesive are reconstructive and medically necessary when all listed criteria are met; duplex reflux must be >= 500 ms measured by standing or reverse Trendelenburg duplex ultrasoundduplex reflux >= 500 ms

See policy for full list of required clinical criteria

Incompetent Perforator Veins — distinction of acceptable and unproven methods

Incompetent Perforator Veins: Ablation of incompetent perforator veins using RFA or EVLA is reconstructive and medically necessary when all listed criteria are met (standing/reverse Trendelenburg duplex demonstrating perforator reflux >= 500 ms and diameter >= 3.5 mm, located beneath a healed or active venous stasis ulcer, and not secondary to acute DVT); ablation using endovenous foam sclerotherapy and/or cyanoacrylate‑based adhesive is unproven and not medically necessary due to insufficient evidenceperforator reflux >= 500 ms; diameter >= 3.5 mm

Per policy, endovenous foam sclerosant or cyanoacrylate for perforators is not supported

Sclerotherapy coverage limits

Sclerotherapy sessions limits: CPT codes 36470 and 36471 (sclerotherapy for non‑truncal, non‑telangiectasia veins) are covered for up to three sessions per leg within a rolling 12‑month period; CPT 36468 for telangiectasias/spider veins is considered cosmetic and excluded<= 3 sessions per leg per year for 36470/36471

Refer to coding section and AMA guidance for foam truncal injections (CPT 36465/36466)

Per the policy coding clarifications, CPT code 36468 (sclerotherapy for spider veins/telangiectasias) is considered cosmetic and excluded. CPT codes 36470 and 36471 (sclerotherapy for non-telangiectasia, non-truncal veins) are covered but are limited to up to three sessions per leg within a rolling 12‑month period. A session is defined as one date of service in which CPT 36470 or 36471 is performed; more than three sessions per leg in a 12‑month period is considered cosmetic and excluded.

Treatments directed at spider veins/telangiectasias are categorized as cosmetic and excluded from coverage; therefore sclerotherapy for telangiectasias (CPT 36468) is not covered. In addition, endovenous ablation of reticular or telangiectatic veins is not considered reconstructive and is not medically necessary. When sclerotherapy targets a truncal extremity vein and ultrasound‑guided non‑compounded foam injection is used, providers should follow AMA guidance and consider CPT 36465/36466 for coding.

Key trial exclusion criteria frequently used in pivotal randomized studies included prior treatment of the target GSV, reflux limited to the SSV or accessory GSV (AAGSV), symptomatic peripheral arterial disease, history of DVT or PE, aneurysm of the target GSV > 12 mm, body mass index > 35, active treatment for hypercoagulable disorders or current anticoagulation, sensitivity to cyanoacrylate adhesives, and CEAP class 6.

Available peer‑reviewed evidence for cyanoacrylate embolization (CAE) or endovenous foam sclerotherapy specifically for incompetent perforator veins is limited and methodologically weak. The policy notes that current literature is insufficient to establish safety and efficacy for these techniques in perforator veins and recommends that additional robust randomized trials with longer follow‑up are required.

The porcine bioprosthetic VenoValve remains investigational: published evidence is limited to small feasibility cohorts with short follow‑up, and the device is not yet FDA approved. Larger randomized controlled trials and longer‑term outcome data are needed before routine coverage can be considered.

Information on FDA approvals for devices and agents in this policy is provided for context only; FDA approval alone is not a basis for coverage. Device approvals are informational and do not in themselves establish that a service meets medical necessity criteria.

Ablation of incompetent perforator veins using endovenous foam sclerotherapy or cyanoacrylate‑based adhesive is considered unproven and not medically necessary due to insufficient evidence of efficacy for this indication. The policy specifically distinguishes that radiofrequency or endovenous laser ablation remain the accepted reconstructive approaches when perforator criteria are met, whereas CAE and foam sclerotherapy lack robust, comparative data for perforator treatment.

Restating the policy position: ablation of incompetent perforator veins with endovenous foam sclerotherapy or cyanoacrylate adhesive is unproven and not medically necessary. Specific exclusions noted in the policy include lack of robust RCT evidence, small study sizes, short follow‑up, and confounding concurrent treatments in the published series; therefore these methods are not accepted alternatives for perforator ablation in this policy.

The policy explicitly states that endovenous ablation of reticular or telangiectatic veins and cosmetic sclerotherapy are not medically necessary and are excluded from coverage. CPT 36468 for spider veins/telangiectasias is cosmetic and excluded; CPTs 36470/36471 for non‑telangiectatic, non‑truncal sclerotherapy are limited to three sessions per leg per 12‑month rolling year.

Mechanochemical ablation (MOCA) may be considered not medically necessary as a first‑line option for primary truncal GSV incompetence when more effective alternatives are available. Systematic reviews and meta‑analyses report lower GSV closure rates and less VCSS improvement with MOCA compared with RFA, EVLA, and cyanoacrylate in several pooled analyses, raising concerns about long‑term durability versus established endovenous thermal ablation (EVTA) techniques.

When endovenous thermal ablation (EVTA: EVLA or RFA) is available and suitable, use of MOCA as the initial first‑line treatment may be less appropriate because MOCA has demonstrated lower anatomical occlusion rates at one year and higher recanalization in some analyses; guidelines therefore recommend EVTA as the preferred first‑choice treatment in most patients.

The policy references evidence that physician‑compounded ultrasound‑guided foam sclerotherapy (UGFS) is suggested to have inferior long‑term outcomes compared with established therapies such as EVLA, RFA, or high ligation and stripping. Meta‑analyses and comparative reviews indicate higher recurrence and lower long‑term closure rates for UGFS versus thermal ablation or surgical approaches when long‑term durability is prioritized.

A prior policy position noted cyanoacrylate‑based adhesive for endovascular embolization had previously been considered unproven and not medically necessary for some venous indications. The current policy updates clarify which uses remain unproven (for example, perforator veins) while recognizing that cyanoacrylate adhesive has higher‑quality comparative evidence for truncal GSV/SSV closure in other contexts.

Coding and Diagnostic Thresholds

Applicable CPT/HCPCS Codesmixed

0744T	Insertion of bioprosthetic valve, open, femoral vein, including duplex ultrasound imaging guidance
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
36468	Injection(s) of sclerosant for spider veins (telangiectasia)
36470	Injection of sclerosant; single incompetent vein (other than telangiectasia)
36471	Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg
36473	Endovenous mechanochemical ablation; first vein treated
36474	Endovenous mechanochemical ablation; subsequent veins treated in same extremity, add-on
36475	Endovenous radiofrequency ablation; first vein treated
36476	Endovenous radiofrequency ablation; subsequent vein(s) treated in same extremity, add-on

1–10 of 22

1/3

Applicable Codes / SclerotherapyCPT

36465	Sclerotherapy, injection of non-compounded foam sclerosant with ultrasound compression maneuvers; single incompetent extremity truncal vein (per AMA guidance for truncal vein foam injections)
36466	Sclerotherapy, injection of non-compounded foam sclerosant with ultrasound compression maneuvers; multiple incompetent truncal veins, same leg (per AMA guidance for truncal vein foam injections)
36468	Sclerotherapy for telangiectasias/spider veins (considered cosmetic)
36470	Injection of sclerosant; single incompetent vein (other than telangiectasia) — covered up to three sessions per leg within a 12-month period
36471	Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg — covered up to three sessions per leg within a 12-month period

Vein diameter and reflux thresholds — GSV/SSV/Accessory; Perforator

GSV/SSV/Accessory diameter>= 3 mm

GSV/SSV/Accessory reflux duration>= 500 ms

Perforator vein diameter>= 3.5 mm

Reflux duration threshold

Duplex reflux duration threshold> 500 ms

ContextMeasured on duplex ultrasound in standing or reverse Trendelenburg position

Applies to

Prior Authorization, Documentation, and Billing Actions

Note

Applicable Codes — informational

Listing of applicable procedure and diagnosis codes is provided for reference only. Inclusion of a code does not guarantee coverage or payment; medical records and supporting documentation may be requested to verify that clinical criteria are met.

Applicable Codes lists are informational — prior authorization or coverage is not determined solely by coding.
FDA approvals for devices (see FDA section) are informational and do not in themselves mandate prior authorization.

Prior Authorization

Prior authorization and cosmetic exclusions

Cosmetic exclusions (e.g., spider veins/telangiectasias and cosmetic sclerotherapy) are explicitly excluded and may be denied without prior authorization. For procedures that are potentially covered, prior authorization may be required where indicated in benefit plan documents.

Cosmetic Sclerotherapy (treatment of spider veins/telangiectasias; CPT 36468) — exclusion that may trigger denial.
Prior authorization guidance should be checked for services that are not explicitly excluded.

Background and Evidence Overview

Varicose veins result from venous valve failure leading to reflux and vein dilation. Duplex ultrasound performed in the standing or reverse Trendelenburg position is the diagnostic gold standard to document axial reflux; the policy requires duplex documentation of reflux duration (commonly defined as >= 500 milliseconds) and vein diameters when assessing candidacy for interventions.

inv-07 (evidence overlap): Trial-based coverage/assessment criteria as they inform evidence review

Trial‑based coverage/assessment criteria informing evidence review (overlap):

Trial noninferiority elements: Randomized trials comparing CAC to RFA used symptomatic GSV incompetence with duplex‑documented reflux >= 0.5 seconds, excluded prior GSV treatment and other contraindications, and defined primary endpoint as complete target vein closure at three months with scheduled long‑term follow‑up to 24–60 monthsclosure at 3 months; reflux >= 0.5 s

Used to assess noninferiority in pivotal RCTs (VeClose, Alhewy)

inv-08 (evidence overlap): CAE/CAC evidence summary for background evidence synthesis

CAE/CAC evidence summary for background evidence synthesis (overlap):

Definitions and Glossary

Accessory Vein

DefinitionAccessory saphenous veins are venous segments ascending parallel to the great saphenous vein located more superficially above the saphenous fascia (includes anterior/posterior GSV and circumflex veins)

IncludesVein of Giacomini as a cranial extension of the SSV before penetrating muscular fascia

ContextUsed to identify target truncal tributary veins for ablation when symptomatic and meeting duplex criteria

Axial Reflux

DefinitionAxial reflux is uninterrupted retrograde venous flow from the groin to the upper calf for the GSV (knee to ankle for SSV)

MeasurementDocumented on duplex ultrasound with measurements at least 5 cm apart for accessory GSVs

Policy Changes and Revision History

2026-04-01revisionLatest

Template update; removed content/language pertaining to the state of Louisiana and other non-clinical template edits.

2025-10-01administrative_revision

State-specific application note added for Nebraska (policy does not apply to Nebraska); administrative update to state applicability.

2025-08-01material_revision

Effective coverage rationale update: replaced prior language to explicitly include initial and subsequent treatment of GSV, SSV, and Accessory veins with RFA, EVLA, stripping with ligation and excision, endovenous foam sclerotherapy, and cyanoacrylate-based adhesive as reconstructive and medically necessary when all listed criteria are met; set policy effective date.

Policy Summary

PayerUnitedHealthcare

PolicySurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins

Policy CodePolicy CS117.AB

Change TypeCriteria and coding revisionsmaterial coverage updates

Effective Date08/01/2025

Next Review DateN/A

Key ActionWhen requesting prior authorization, provide standing or reverse Trendelenburg duplex ultrasound documenting vein diameter and reflux (>=500 ms) and clinical impairment to support coverage.

SourceLink

On This Page

VenoValve evidence is limited to small feasibility cohorts and the device is not FDA approved; consider investigational status when making coverage determinations

Limited evidence and regulatory status noted

Guideline‑based recommendations; mixed grades

Superficial truncal veins (GSV, SSV, Accessory) and specified deep/perforating veins

Pathologic perforator diameter threshold

Perforator diameter threshold>= 3.5 mm

Measurement methodDiameter measured on duplex ultrasound in standing or reverse Trendelenburg position

Clinical contextRequired for consideration of perforator ablation when associated with ulcer or symptomatic disease

Reflux duration

Reflux duration (policy threshold)>= 500 ms

Definition sourceSVS/AVF/AVLS/SIR guidance defining reflux as > 500 ms on duplex

Required positionStanding or reverse Trendelenburg duplex study

Perforator vein diameter

Perforator vein diameter>= 3.5 mm

Applies toPathologic perforating veins in patients with varicose veins (CEAP C2)

Measured byDuplex ultrasound in standing or reverse Trendelenburg position

Duplex reflux duration — measurement requirements

Duplex reflux duration (explicit policy text)>= 500 milliseconds

Duplex position requirementStanding or reverse Trendelenburg required for measurement

Applies toGSV, SSV, Accessory and perforating veins per revised policy language

Denial Risk

Trial-based exclusion conditions — potential denial triggers

Trial exclusion criteria from pivotal RCTs can inform denial decisions when a member's clinical presentation matches trial exclusions (e.g., active anticoagulation, active DVT/PE, BMI >35, large target vein aneurysm >12 mm, sensitivity to adhesives).

Examples of trial-based exclusion conditions that may be used as denial triggers: prior treatment of the target vein, symptomatic peripheral arterial disease, history of DVT or PE, active anticoagulation, BMI > 35, aneurysm of target vein > 12 mm, sensitivity to device materials.
Presence of these conditions in the medical record may warrant denial or requests for additional documentation.

Prior Authorization

Prior authorization: evidence and documentation

Prior authorization requests must include documentation of indications, prior conservative therapy where required, and the specific procedure performed. Expect requests for operative notes, duplex ultrasound reports, and symptom severity measures used in study populations.

Required indications and documentation expectations include: history and physical, indication for procedure, prior conservative therapy and duration, and planned procedure type.
Document whether the procedure is adjunctive (e.g., tributary treatment) or a primary truncal vein ablation.

Prior Authorization

Prior authorization for MOCA/VenoValve — limited evidence

MOCA and VenoValve have limited or investigational evidence. Prior authorization may be required and payers may request additional documentation to support medical necessity; coverage is less likely when evidence is limited.

MOCA (mechanochemical ablation) demonstrated inferior closure and symptom improvement versus RFA/EVLA/CAC in some meta-analyses — anticipate requests for additional justification when MOCA is proposed.
VenoValve remains investigational with very limited published experience; documentation of participation in clinical trials or rationale for use may be required.

Note

Device approvals — informational

FDA device approvals are informational only. An FDA approval does not by itself define coverage or remove the need for prior authorization when the benefit plan or policy requires it.

Examples: ClariVein infusion catheter (K071468), VenaSeal Closure System (P140018), Varithena (polidocanol foam) — approved devices referenced for information.
Prior authorization requirements are determined by the payer and benefit plan, not by FDA approval status alone.

Billing Rule

Sclerotherapy coding and coverage notes

Sclerotherapy coding notes: CPT 36465/36466 apply when ultrasound-guided foam into truncal veins with compression maneuvers is performed; CPT 36470/36471 are limited to up to three sessions per leg per rolling 12-month period. Cosmetic sclerotherapy is excluded and may be denied.

CPT 36465/36466 — ultrasound-guided foam sclerotherapy for truncal veins (per AMA guidance).
CPT 36470/36471 — covered up to three sessions per leg per 365-day rolling period; >3 sessions/leg/12 months considered cosmetic and excluded.

Documentation Required

Duplex ultrasound and follow-up documentation

Duplex ultrasound is the diagnostic test of choice and essential for prior authorization and documentation. Reports should include patient position (standing or reverse Trendelenburg), target vein identified, reflux duration (>= 500 ms threshold), and vein diameters where applicable.

Required duplex elements: standing or reverse Trendelenburg position, measured reflux duration (report reflux >= 500 ms for truncal veins and perforators), vein diameter measurements, and localization of reflux (GSV, SSV, AAGSV, PAGSV, perforators).
Follow-up duplex assessments are typically performed at early postprocedure visits and at defined intervals (e.g., day 3, 1 month, 3 months, then 6-monthly up to 2–3 years) — include baseline and planned follow-up imaging in documentation.

Documentation Required

Procedure-specific documentation

Procedure-specific documentation should clearly support the diagnosis and the exact procedure performed (e.g., EVTA, CAC, MOCA, UGFS, phlebectomy). Include operative reports, devices used, adjunctive treatments, and rationale for technique selection (especially if non-preferred or investigational methods are chosen).

Document target veins, laterality, number of veins treated, device or sclerosant used, anesthesia type, adjunctive procedures (phlebectomy, tributary sclerotherapy), and expected clinical benefit.
If selecting a non-thermal or novel technique (CAC, MOCA, PEM), include reasons why first-line EVTA is not appropriate or feasible.

Documentation Required

Documentation of duplex ultrasound — reflux thresholds

Documentation of duplex ultrasound demonstrating reflux is required: standing or reverse Trendelenburg duplex showing duration of reflux >= 500 ms for target truncal and perforator veins is a common policy threshold and may be used to determine medical necessity.

Policies commonly require duplex evidence of reflux >= 500 ms for GSV, SSV, accessory veins, and perforators (with perforator diameter thresholds noted in some guidelines).
Ensure the duplex report explicitly states the duration of reversed flow and the patient position during the study.

Step Therapy

Step therapy and preferred-first-step considerations

Consideration of step therapy: guidelines and comparative data support EVTA (endovenous thermal ablation) as the preferred first-step treatment for truncal vein incompetence. Payers may require step therapy favoring established EVTA before approving novel non-thermal methods.

Preferred-first-step: EVTA (RFA or EVLA) is generally recommended over novel non-thermal methods (e.g., MOCA, CAC) when available and anatomically feasible.
When a non-thermal technique is proposed, include documentation explaining why EVTA is contraindicated, not available, or unsuitable for the patient.

CAE/CAC evidence synthesis: Pivotal trials and cohort studies report high short‑ and mid‑term closure rates for CAE/CAC with sustained symptom and QOL improvements; long‑term freedom from recanalization estimates in some studies are comparable to RFA, but studies have limitations including limited randomization, follow‑up attrition, and heterogeneous adjunctive treatments

Findings summarized from VeClose, WAVES, Proebstle, and extensions

RelevanceAxial reflux indicates truncal vein incompetence and may guide need for endovenous ablation

Moderate to Severe Pain (VCSS)

Moderate pain (VCSS)Daily pain or discomfort interfering with, but not preventing, regular activities

Severe pain (VCSS)Daily pain or discomfort that limits most regular activities

UseVCSS pain categories used to define functional impairment qualifying for treatment

Varicose Veins (CEAP C2)

DefinitionVaricose veins are dilated subcutaneous tributaries >= 3 mm in diameter corresponding to CEAP Class C2

Clinical classCEAP C2 used to categorize visible varicosities when assessing treatment eligibility

Relation to policyVaricose vein size threshold aligns with duplex and clinical criteria for intervention

Endovenous Ablation

DefinitionEndovenous ablation: minimally invasive closure of damaged veins using thermal energy (radiofrequency or laser)

PurposeSeals off damaged truncal veins to eliminate reflux and improve symptoms/QOL

ContextPreferred first-line treatment for symptomatic axial truncal reflux when available

Cyanoacrylate embolization

DefinitionCyanoacrylate embolization: endovascular adhesive closure using medical-grade cyanoacrylate glue (e.g., VenaSeal) to occlude incompetent truncal veins without tumescent anesthesia

EvidenceRCTs (e.g., VeClose) and cohort studies report high closure rates and sustained symptom/QOL improvements

LimitationsSome studies limited by follow-up rates and lack of blinding; long-term data continue to accrue

PEM / Varithena

DefinitionPEM (Varithena): polidocanol 1% endovenous microfoam generated by a proprietary canister for ultrasound-guided IV injection to sclerose and close varicose veins

IndicationUsed for symptomatic, visible varicose veins; randomized trials show symptom and appearance improvement vs placebo

Comparative dataNetwork meta-analysis found PEM not statistically different from EVTA for vein closure in available studies

Mechanochemical ablation (MOCA)

DefinitionMechanochemical ablation (MOCA): a non-thermal method combining mechanical endothelial disruption via a rotating wire with infusion of a sclerosing agent (e.g., ClariVein)

MechanismMechanical abrasion plus chemical sclerosant induces sclerosis and occlusion of the vein

Evidence noteSystematic reviews show MOCA may have lower GSV closure and VCSS improvement vs RFA/EVLA/CAC

Stripping and Ligation

DefinitionStripping and ligation: surgical tying off (ligation) and removal (stripping) of saphenous veins, often used when endovenous treatment is not available or appropriate

IndicationsMay be indicated for certain anatomies or when EVTA expertise/technology is unavailable

Relation to outcomesHistorically effective; EVTA preferred due to less pain and faster recovery when available

Complete closure / occlusion

DefinitionComplete closure/occlusion: absence of flow in the target truncal vein on duplex ultrasound at follow-up visits (commonly primary endpoint at 3 months in trials)

Use in trialsPrimary outcome for noninferiority comparisons (e.g., VeClose) assessed at 3 months with longer-term follow-up available

AssessmentDuplex ultrasound used to confirm occlusion at standardized intervals post-procedure

Cyanoacrylate adhesive (CAE/CAC)

DefinitionCyanoacrylate adhesive (CAE/CAC): medical-grade cyanoacrylate glue used endovenously (e.g., VenaSeal) to occlude incompetent truncal veins without tumescent anesthesia

ExamplesVenaSeal Sapheon Closure System

Clinical outcomesStudies report high closure rates and QOL improvements with acceptable safety profiles

Polidocanol endovenous microfoam (PEM/Varithena)

DefinitionPolidocanol endovenous microfoam (PEM/Varithena): pharmaceutical-grade polidocanol foam injected endovenously to sclerose and close varicose veins

Study evidenceRandomized, placebo-controlled trials show symptom/appearance benefit vs placebo; network analyses compare PEM to EVTA

AdministrationUltrasound-guided IV injection using a proprietary canister-generated foam

Mechanochemical ablation (MOCA)

DefinitionMechanochemical ablation (MOCA): non-thermal technique combining mechanical endothelial disruption and chemical sclerosant infusion to ablate truncal veins

Device exampleClariVein system

Evidence caveatLimited RCT and long-term data; systematic reviews show lower occlusion vs some alternatives

Reflux (>= 500 ms)

DefinitionReflux: reversed flow defined as a minimum value > 500 ms of reversed flow on duplex ultrasound in superficial truncal and specified deep/perforating veins

Measurement positionMeasured on duplex ultrasound in standing or reverse Trendelenburg position

Applies toGSV, SSV, accessory GSVs, tibial/deep femoral and perforating veins per SVS guidance

Axial reflux (groin to calf flow)

DefinitionAxial reflux: uninterrupted retrograde venous flow from the groin to the calf (GSV) or knee to ankle (SSV)

Clinical relevanceIndicates truncal vein incompetence and guides treatment planning for endovenous ablation

MeasurementDocumented on standing or reverse Trendelenburg duplex ultrasound

Reflux (minimum > 500 ms reversed flow)

DefinitionReflux: minimum > 500 ms of reversed flow on duplex ultrasound (policy and guideline consistent)

Clinical measurementDuplex in standing or reverse Trendelenburg; interpretations describing moderate to severe reflux acceptable

UseThreshold used to determine eligibility for endovenous interventions in policy

Pathologic perforating vein (>= 3.5 mm and >= 500 ms)

DefinitionPathologic perforating vein: outward flow duration >= 500 ms and diameter >= 3.5 mm on duplex ultrasound in patients with varicose veins (CEAP C2)

Measurement positionStanding or reverse Trendelenburg duplex required

Clinical implicationMeets size/reflux criteria for consideration of perforator ablation (RFA or EVLA)

Axial reflux (duplicate)

DefinitionAxial reflux: uninterrupted retrograde venous flow from the groin to the calf

ApplicabilityUsed for GSV; analogous definitions for SSV and accessory veins per policy

MeasurementDocumented on duplex ultrasound

Junctional reflux

DefinitionJunctional reflux: reflux limited to the saphenofemoral junction (SFJ) or saphenopopliteal junction (SPJ)

Clinical noteMay be relevant when localization of reflux is limited to junctions rather than axial truncal flow

MeasurementDocumented on duplex ultrasound per standard technique

Superficial Vein

DefinitionSuperficial Vein: veins located above the muscular fascia

IncludesGreat and small saphenous veins and their superficial tributaries

RelevanceDifferentiates superficial from deep venous system for treatment planning

Telangiectasias/Spider Veins

DefinitionTelangiectasias/Spider Veins: dilated small superficial veins < 1 mm in diameter occurring predominantly in the lower extremities

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

Clinical noteDifferentiate from varicose veins (>=3 mm) when assessing medical necessity

Tributary Vein

DefinitionTributary Vein: small superficial veins in the legs that run close to the skin within the superficial plane of the subcutaneous layer

RelationTributary veins include varicose tributaries and reticular veins that may arise from incompetent truncal veins

Treatment noteAmbulatory phlebectomy or adjunctive procedures may target symptomatic tributary veins

2025-08-01material_revision

Added 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.

2025-08-01material_revision

Revised duplex ultrasound criteria to reference Accessory Veins and clarified reflux thresholds (>= 500 ms) with requirement for standing or reverse Trendelenburg duplex studies and added criterion that perforator veins not be secondary to acute DVT.

2025-08-01material_revision

Updated coding notations: removed CPT 37500 and 37799; removed notation for 37241; clarified use of CPT 36465/36466 per AMA guidance for extremity truncal foam injections; and changed coverage listing for sclerosant/telangiectasia codes (36468 cosmetic; 36470/36471 covered up to three sessions per leg per year).

2025-08-01administrative_revision

Added new definitions for Superficial Vein, Telangiectasias/Spider Veins, and Tributary Vein and removed definitions for Cosmetic Procedures and Reconstructive Procedures.