Insufficiency and Varicose Veins (for Louisiana Only)
Medical policy governing coverage and medical necessity criteria for evaluation and treatment of venous insufficiency and varicose veins for Louisiana UnitedHealthcare Community Plan members.
Policy retired for Louisiana membership effective April 1, 2026 and multiple coverage criteria, coding notations, and definitions were updated prior to retirement.
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.
Expanded language to consider initial and subsequent treatment of the 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 criteria are met.
Coding notation updated to remove CPT codes 37500 and 37799 and to change coverage statements for sclerotherapy CPT codes (36465/36466 guidance and coverage of 36470/36471 up to three sessions per leg per year).
Added instruction to refer to CPT code 36465 or 36466, per AMA coding guidance, when the targeted vein is an extremity truncal vein and injection of non‑compounded foam sclerosant with ultrasound guided compression maneuvers is performed.
Removed notation pertaining to CPT code 37241.
Replaced earlier coverage statement that CPT codes 36465, 36466, 36470, and 36471 are covered for sclerotherapy up to three sessions per leg within a year with a statement that CPT codes 36470 and 36471 are covered for non‑truncal, non‑telangiectasia sclerotherapy up to three sessions per leg within a year.
Removed CPT codes 37500, 37799, and CPT code 37241 from the applicable codes section/notations.
Updated definitions for Accessory Vein, Great Saphenous Vein, Sclerotherapy, and Small Saphenous Vein; removed definition of Cosmetic Procedures.
Updated Description of Services, Clinical Evidence, FDA, and References sections to reflect the most current information and archived previous policy version CS117LA.S.
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