ModifiedUnitedHealthcarePolicy CS117NJ.V

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

State-specific UnitedHealthcare Community Plan medical policy governing surgical and ablative treatments for venous insufficiency and varicose veins for New Jersey members.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS117NJ.V

Change TypeCriteria and coding revisionsmodality clarifications

Effective DateSeptember 1, 2025

Next Review DateN/A

Key ActionObtain and document a standing or reverse Trendelenburg duplex ultrasound showing vein diameters and reflux duration (≥500 ms for truncal/accessory veins; ≥3.5 mm and ≥500 ms for perforators) to support prior authorization and medical necessity.

SourceLink

POLICY UPDATE CHANGES

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

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

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

Expanded 'reconstructive and medically necessary' statement to include treatment of GSV, SSV, and Accessory Veins with radiofrequency, endovenous laser, stripping with ligation and excision, endovenous foam sclerotherapy, and/or cyanoacrylate-based adhesive when listed criteria are met.

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

Added requirement that incompetent perforator veins are not secondary to acute deep vein thrombosis and standardized duplex ultrasound to standing or reverse Trendelenburg position.

Updated ambulatory phlebectomy references and removed references to certain InterQual phlebectomy items (Hook and Microphlebectomy).

Removed CPT codes 37500 and 37799 from Applicable Codes.

Updated coding notations including guidance to refer to CPT 36465/36466 for truncal extremity foam sclerotherapy and clarified coverage limits for CPT 36470/36471.

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.

3.0 mmGSV/SSV/accessory min diameter

>=500 msTruncal reflux threshold

3.5 mmPerforator min diameter

Up to 3Sclerotherapy sessions/leg/yr

C0–C6CEAP classes referenced

34%UGFS anatomic success ≥5y

Coverage Criteria and Clinical Policy

Covered: Ablation/Stripping/Sclerotherapy/Cyanoacrylate for truncal veins

Thermal and non‑thermal treatments for GSV, SSV, and Accessory Veins are considered reconstructive and medically necessary when ALL of the following are met:

Eligibility for ablation/stripping/sclerotherapy/cyanoacrylate: 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 or trauma to the skin; documented superficial thrombophlebitis; documented venous stasis dermatitis causing functional or physical impairment; or moderate to severe pain causing functional or physical impairment.

from policy list

Vein diameter criteria: GSV must be >= 3.0 mm when measured at the proximal thigh immediately below the saphenofemoral junction; SSV or Accessory Veins must measure >= 3.0 mm in diameter immediately below the appropriate junction, measured by duplex ultrasonography.GSV/SSV/Accessory >= 3.0 mm

measured by duplex ultrasonography in standing or reverse Trendelenburg

Reflux duration: Duplex ultrasound study performed in the standing or reverse Trendelenburg position shows duration of reflux >= 500 milliseconds for the GSV, SSV, or Accessory Veins.>= 500 ms

interpretations reporting 'moderate to severe reflux' are acceptable

Covered: Ablation of incompetent perforator veins (RF or laser)

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

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

Perforator diameter: Perforator vein size is >= 3.5 mm.>= 3.5 mm

Perforator reflux duration: Perforating vein reflux of >= 500 milliseconds.>= 500 ms

Ulcer relation:

Ligation: covered and not medically necessary uses

Ligation indications: Ligation at the saphenofemoral junction as a stand-alone procedure is proven and medically necessary 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.

Not covered ligation procedures: The following are unproven and not medically necessary for treating venous reflux: 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; and ligation at the saphenofemoral junction as an adjunct to radiofrequency ablation or endovenous laser ablation of the main saphenous veins.

Ambulatory phlebectomy

Ambulatory phlebectomy is proven and medically necessary in certain circumstances; medical necessity clinical coverage criteria reference InterQual® CP: Procedures, Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein.

See InterQual criteria

Unproven/Not Medically Necessary Procedures

Unproven procedures: Endovenous mechanochemical ablation (MOCA) of varicose veins and porcine bioprosthetic valve implantation into the femoral vein (e.g., VenoValve) are unproven and not medically necessary for treating venous reflux due to insufficient evidence of efficacy.

Medically necessary treatments

Covered when ALL of the following are met

General medical necessity: Endovenous ablation (thermal or non‑thermal), mechanochemical ablation, foam sclerotherapy, and surgical ligation/stripping are considered treatment options for symptomatic venous reflux and varicose veins when clinically indicated and supported by diagnostic duplex ultrasound and CEAP classification.

Supported by clinical evidence summarized in policy (systematic reviews, RCTs, cohort data).

Cosmetic/Excluded Services

Not covered

Cosmetic exclusions: Treatments for spider veins and/or telangiectasias (cosmetic sclerotherapy) and endovenous ablation of reticular or telangiectatic veins are excluded from coverage.

Evidence-based coverage considerations

Summary of evidence and comparative effectiveness findings

CAE vs Thermal Ablation: Randomized evidence (VeClose RCT) demonstrates cyanoacrylate adhesive closure (CAE, VenaSeal) is noninferior to radiofrequency ablation (RFA) for GSV closure at early timepoints with similar closure rates reported through mid‑term follow‑up (3–36 months) and limited longer‑term cohort data to 60 months; trials had limitations including lack of blinding and loss to follow‑up.

VeClose pivotal RCT and follow‑ups

CAE procedural considerations: CAE can be performed without tumescent anesthesia and is associated with less ecchymosis and similar procedural pain versus RFA; common adverse events include phlebitic reactions.

Trial reports (VeClose publications)

CAE for perforator veins: Evidence for CAE treating incompetent perforator veins is limited to small studies and retrospective series and is insufficient to establish safety and efficacy.

Further randomized trials and long‑term outcomes needed

Coverage logic: thermal-first with limited non-thermal roles

Coverage stance and criteria logic inferred from evidence and guideline statements in these sections:

Preferred first-line: Endovenous thermal ablation (EVTA: EVLA or RFA) is recommended as the preferred first‑line treatment for GSV and SSV incompetence in most patients.

ESVS guideline recommendation

Acceptable alternatives: Non‑thermal methods (MOCA, CAE) and ultrasound‑guided foam sclerotherapy (UGFS/PEM) may be considered in specific clinical contexts: small diameter saphenous trunks (<6 mm), tortuous or recurrent anatomy where cannulation is difficult, or when a non‑thermal approach is preferred or thermal options are contraindicated.saphenous trunk diameter < 6 mm

ESVS and NICE guidance

MOCA comparative outcome: MOCA shows lower one‑year anatomic occlusion rates compared with EVTA in pooled analyses; coverage may require demonstration that thermal ablation is unsuitable or contraindicated before MOCA is used.

Guideline recommendations / Coverage-relevant clinical criteria

Guideline-based recommendations and appropriate‑use statements (selection of notable points):

Preference for EVTA over stripping in many contexts: For symptomatic axial reflux of the GSV or SSV, EVTA (endovenous laser or radiofrequency) is recommended over high ligation and stripping because of less post‑procedure pain, lower morbidity, and earlier return to activity; if endovenous options are unavailable or anatomy precludes them, high ligation and stripping is recommended.

SVS/ESVS/SIR guidance

Nonthermal options guidance: Nonthermal techniques (cyanoacrylate adhesive closure, mechanochemical ablation, foam sclerotherapy) may be considered when a nonthermal technique is preferred or when anatomy/technical factors limit endovenous cannulation; UGFS may be considered for saphenous trunks <6 mm.saphenous trunk diameter < 6 mm

ESVS, NICE statements

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

Covered indications (overview)

Covered when ALL of the following are met (overview):

Permitted modalities overview: 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 are considered reconstructive and medically necessary when all listed clinical and diagnostic criteria are met.

Details of the listed clinical criteria are specified in the policy sections above (symptoms, duplex findings, diameters, reflux thresholds).

Perforator veins (thermal techniques): Ablation of incompetent perforator veins using radiofrequency ablation or endovenous laser ablation is considered reconstructive and medically necessary when all listed perforator criteria (duplex in standing or reverse Trendelenburg, diameter >= 3.5 mm, reflux >= 500 ms, not secondary to acute DVT, and relation to ulcer when applicable) are met.perforator reflux >= 500 ms; diameter >= 3.5 mm

Refer to perforator criteria section

Not medically necessary / Unproven

Not covered / Not medically necessary when ANY of the following apply:

Perforator veins (non‑thermal techniques): 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.

CPT code 36468 (injection(s) of sclerosant for spider veins/telangiectasia) is considered cosmetic and excluded from coverage. For non-telangiectatic sclerotherapy, CPT codes 36470 and 36471 are covered for up to three sessions per leg within a 12‑month period; more than three sessions per leg within a year is considered cosmetic and excluded. When non‑compounded foam sclerosant with ultrasound‑guided compression maneuvers is used for a truncal extremity vein, refer to AMA guidance and CPT codes 36465 or 36466 for coding.

Cosmetic sclerotherapy and procedures directed at spider veins/telangiectasias are explicitly excluded from coverage as they are considered cosmetic and do not improve a functional, physical, or physiological impairment. Endovenous ablation of reticular or telangiectatic veins is similarly not reconstructive and is excluded. Providers should code spider‑vein treatments with CPT 36468 and understand these services are not covered; non‑telangiectatic sclerotherapy codes 36470/36471 remain subject to the session limits described in policy.

Clinical trial exclusion criteria commonly cited in the evidence base can inform patient selection in practice. Examples used in randomized trials include exclusion for active or prior deep venous thrombosis/pulmonary embolism, prior treatment of the target great saphenous vein, reflux in the small or accessory saphenous vein (SSV/AAGSV), symptomatic peripheral arterial disease, aneurysm of the target GSV > 12 mm, body mass index > 35, active anticoagulation, sensitivity to cyanoacrylate adhesives, and CEAP class 6. These trial‑level exclusions indicate populations in which results may not generalize and may affect procedural candidacy or expected outcomes.

Evidence for cyanoacrylate adhesive (CAE) specifically treating incompetent perforator veins is limited to small series and retrospective reports; available data are insufficient to establish safety and long‑term efficacy. Similarly, endovenous foam sclerotherapy for perforator veins lacks robust randomized controlled trial evidence. The policy therefore notes that further well‑designed RCTs and longer‑term outcomes are required before these approaches can be considered established for perforator ablation.

VenoValve implantation is an early investigational approach with evidence limited to small first‑in‑human and early cohort reports; it is not currently FDA‑approved. Given the small sample sizes and short follow‑up in the published series, use of VenoValve outside of clinical trials is investigative.

NICE guidance supports the use of cyanoacrylate glue occlusion and MOCA only when standard clinical governance arrangements are in place. The guidance emphasizes appropriate operator training in venous ultrasound, informed discussion of alternatives with the patient, and local arrangements for consent, audit, and follow‑up; the referenced NICE fragment does not list specific procedural exclusions.

The policy explicitly states that ablation of incompetent perforator veins using cyanoacrylate‑based adhesive or endovenous foam sclerotherapy is considered unproven and not medically necessary due to insufficient evidence of efficacy. This wording should be applied when documenting coverage decisions for perforator vein ablation using these techniques.

Techniques identified as unproven or not medically necessary in this policy include ablation of perforator veins using endovenous foam sclerotherapy or cyanoacrylate adhesive, endovenous mechanochemical ablation (MOCA) for certain indications, and listed ligation procedures when used as stand‑alone treatments for venous reflux. The policy also notes porcine bioprosthetic valve implantation (e.g., VenoValve) remains investigational outside of clinical trials.

Cosmetic exclusions are restated: treatments for spider veins/telangiectasias are considered cosmetic and not covered. CPT 36468 is identified as the code for spider‑vein sclerotherapy and is excluded; non‑telangiectatic sclerotherapy with CPT 36470/36471 is subject to a limit of up to three sessions per leg within a 12‑month period.

The policy concludes that current evidence is insufficient to determine the comparative effectiveness of cyanoacrylate adhesive (CAE) and polidocanol endovenous microfoam (PEM) versus all established modalities across all indications. Systematic reviews and technology assessments indicate favorable short‑term closure for CAE and symptomatic benefit for PEM in some trials, but heterogeneity, limited head‑to‑head data, and short follow‑up leave important comparative effectiveness questions unresolved.

Endovenous foam sclerotherapy for perforator veins has limited evidence and does not demonstrate clear benefit compared with established therapies; MOCA has shown lower anatomic occlusion rates at one year compared with EVTA in pooled analyses. Because of these evidence limitations, such approaches may be considered lower priority or not medically necessary for certain perforator or large‑diameter truncal vein indications.

Guideline panels recommend caution in using truncal vein diameter alone to determine need for ablation in symptomatic CEAP C2 patients. Specifically, the SVS/AVF/AVLS/SIR guidance suggests against relying solely on diameter to select patients for venous ablation, underscoring the need to consider symptoms, reflux parameters, and overall clinical context.

The policy history notes removal of prior language that characterized endovascular embolization using cyanoacrylate adhesive as categorically unproven; the current revision instead lists CAE among reconstructive options when criteria are met, while separately clarifying that CAE or foam sclerotherapy for perforator vein ablation remains unproven and not medically necessary. Additionally, CPT codes 37500 and 37799 were removed from the applicable codes as part of coding clean‑up.

Applicable Codes and Coding Guidance

Sclerotherapy / Sclerosant Injection CPT CodesCPTCovered

36465	Injection of non-compounded foam sclerosant with ultrasound compression maneuvers; single incompetent extremity truncal vein (e.g., GSV, accessory saphenous 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), limb or trunk (considered cosmetic for telangiectasias/spider veins)
36470	Injection of sclerosant; single incompetent vein (other than telangiectasia)
36471	Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg

Endovenous Ablation / Mechanochemical, RFA, Laser, Adhesive — First and Subsequent VeinsCPTCovered

36473	Endovenous ablation therapy, percutaneous, mechanochemical; first vein treated
36474	Endovenous ablation therapy, percutaneous, mechanochemical; subsequent vein(s) treated in single extremity (add-on)
36475	Endovenous ablation therapy, percutaneous, radiofrequency; first vein treated
36476	Endovenous ablation therapy, percutaneous, radiofrequency; subsequent vein(s) treated in single extremity (add-on)
36478	Endovenous ablation therapy, percutaneous, laser; first vein treated
36479	Endovenous ablation therapy, percutaneous, laser; subsequent vein(s) treated in single extremity (add-on)
36482	Endovenous ablation therapy by transcatheter delivery of chemical adhesive (e.g., cyanoacrylate); first vein treated
36483	Endovenous ablation therapy by transcatheter delivery of chemical adhesive; subsequent vein(s) treated in a single extremity (add-on)

Surgical / Phlebectomy, Stripping, Ligation CodesCPTCovered

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

Endovenous Ablation — First-Vein Primary CodesCPTCovered

36473	Mechanochemical; first vein treated
36475	Radiofrequency; first vein treated
36478	Laser; first vein treated
36482	Chemical adhesive (cyanoacrylate); first vein treated

Surgical / Phlebectomy and Add-on Adhesive CodesCPTCovered

36474	Mechanochemical; subsequent vein(s) treated in single extremity (add-on)
36476	Radiofrequency; subsequent vein(s) treated in single extremity (add-on)
36479	Laser; subsequent vein(s) treated in single extremity (add-on)
36483	Chemical adhesive (cyanoacrylate); subsequent vein(s) treated in single extremity (add-on)
37700	Ligation and division of long saphenous vein at saphenofemoral junction
37718	Ligation, division, and stripping, short saphenous vein
37722	Ligation, division, and stripping, long saphenous veins
37765	Stab phlebectomy of varicose veins, one extremity; 10-20 stab incisions
37766	Stab phlebectomy of varicose veins, one extremity; more than 20 incisions

FDA Device Approvals / Identifiersmixed

K071468	ClariVein infusion catheter (Vascular Insights) — FDA clearance, Mar 20, 2008
P140018	VenaSeal Closure System — FDA premarket approval (PMA), Feb 20, 2015

Sclerosing Agents (FDA) — NDC / Approval Notesmixed

Asclera (polidocanol)	FDA-approved Mar 2010 for small spider and reticular veins (1–3 mm); not studied for varicose veins >3 mm
Varithena (polidocanol injectable foam)	FDA-approved Nov 25, 2013 for incompetent GSV, accessory saphenous veins and visible GSV varicosities; refer to FDA labeling

Sclerotherapy CPT Guidance and Session LimitsCPT

36465/36466	Use these codes when non-compounded foam sclerosant with ultrasound compression maneuvers is injected into truncal extremity veins (per AMA guidance)
36470/36471	Sclerotherapy for non-truncal (other than telangiectasia) veins; covered up to three sessions per leg within a year
36468	Sclerosant for spider veins/telangiectasias — considered cosmetic

Vein diameter thresholds — GSV/SSV/Accessory >= 3.0 mm; Perforator >= 3.5 mm

GSV/SSV/Accessory minimum diameter>= 3.0 mm

Perforator vein minimum diameter>= 3.5 mm

Duplex reflux duration — threshold values used in policy (>= 500 ms)

Duplex reflux duration (truncal veins)>= 500 milliseconds (0.5 seconds)

Duplex reflux duration (perforator veins)>= 500 milliseconds (0.5 seconds)

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization for Procedural Codes

Prior authorization may be required for procedural codes used to treat venous insufficiency. Submit PA when billing endovenous ablation (thermal), chemical adhesive closure (CAE), surgical ligation/stripping, or sclerotherapy codes as applicable to the member's plan.

Commonly affected CPTs include endovenous ablation and closure codes (e.g., 36475–36479, 36482–36483), ligation/stripping (e.g., 37700, 37718, 37722, 37735), and sclerotherapy/stab phlebectomy codes (e.g., 36465–36471, 37765–37766). Refer to plan-specific PA rules for exact code lists and requirements.

Documentation Required

Expected Diagnostic and Clinical Documentation for Authorization

Authorization submissions typically require diagnostic confirmation of venous reflux by duplex ultrasound and documentation of clinical severity (CEAP class) to support medical necessity.

Duplex ultrasound must be performed standing or in reverse Trendelenburg and document reflux duration (≥ 500 ms for truncal veins; ≥ 500 ms and diameter ≥ 3.5 mm for perforators where applicable).

Background and Rationale

Varicose veins and chronic venous insufficiency result from valvular incompetence producing reflux in superficial, perforator, or deep systems. Duplex ultrasonography with Doppler performed in the standing or reverse Trendelenburg position is the diagnostic standard to document anatomy, measure vein diameters, and quantify reflux duration; these duplex findings underpin eligibility for reconstructive treatments described in the policy.

Definitions and Key Terms

Duplex Ultrasonography — definition & recommended position

Duplex Ultrasonography — definitionNoninvasive B-mode plus Doppler imaging to assess venous anatomy and flow; recommended in standing or reverse Trendelenburg position

Measurement elementsUsed to document vein diameter and reflux duration to guide treatment decisions

RoleConsidered the diagnostic gold standard for superficial venous incompetence

Functional or Physical Impairment — definition & examples

Functional or Physical Impairment — definitionClinical consequences that limit normal activities (e.g., skin ulceration, bleeding, superficial thrombophlebitis, venous stasis dermatitis, or moderate-to-severe pain)

Examples

Policy Update and Revision History

2025-09-01coverage_revisionLatest

Removed prior language that ligation/subfascial/endoscopic surgery for perforating veins was proven and medically necessary in certain circumstances; 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 of efficacy.

2025-09-01coverage_revision

Replaced and expanded the list of reconstructive, medically necessary treatment options to explicitly include endovenous foam sclerotherapy and cyanoacrylate-based adhesive for GSV, SSV, and Accessory Veins when listed criteria are met.

2025-09-01

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS117NJ.V

Change TypeCriteria and coding revisionsmodality clarifications

Effective DateSeptember 1, 2025

Next Review DateN/A

SourceLink

On This Page

Perforating vein lies beneath a healed or active venous stasis ulcer.

Not DVT-related: Perforator insufficiency is not secondary to acute deep vein thrombosis.

PEM vs EVTA: Systematic reviews and network meta‑analysis indicate polidocanol endovenous microfoam (PEM) is not statistically different from endovenous thermal ablation (EVTA) for vein closure and DVT risk, and PEM is superior to physician‑compounded foam for closure in some analyses; data limitations include heterogeneity and variable follow‑up.

Kabnick et al. 2024 and related evidence

MOCA comparative outcomes: Meta‑analyses show mechanochemical ablation (MOCA) has lower anatomic occlusion rates at one year compared with EVTA and may have inferior long‑term durability; evidence quality and long‑term data are limited.

Bontinis et al. 2023; Lim et al. 2023; Witte et al. 2017a

Lim et al. 2023; Bontinis et al. 2023

Foam sclerotherapy for perforator veins: Evidence for endovenous foam sclerotherapy for perforator veins is limited and does not support clear benefit over established therapies; robust RCTs and long‑term outcomes are lacking.

Hager et al.; Lloret et al.

Investigational devices: Devices with limited early‑phase evidence (e.g., VenoValve) are investigational and not supported for routine coverage outside clinical trials pending more evidence.

Early cohort reports and regulatory status

SVS/AVF/AVLS/SIR recommendations

Perforator veins and ulcers: In patients with venous leg ulcers (C6) or healed ulcers (C5) with axial reflux directed to the ulcer bed, ablation of incompetent superficial veins and pathologic perforators (reflux >= 500 ms and diameter >= 3.5 mm) in addition to compression is suggested to aid healing and prevent recurrence; percutaneous techniques (UGFS or EVTA) are recommended over open perforator surgery.perforator reflux >= 500 ms; diameter >= 3.5 mm

SVS/AVF guidance and AUC

Use of duplex ultrasound: Duplex ultrasound scanning is the diagnostic test of choice and documentation of reflux parameters (>= 500 ms) is fundamental to guide treatment.>= 500 ms

SVS/AVF guidance

Code list and authorization implications callout (reference to requiring prior auth per plan/contract)

Coding notePer AMA guidance, only one primary endovenous ablation code may be reported per extremity for the initial vein treated; only one add-on subsequent vein code may be reported per extremity regardless of number of additional veins treated.

Document vein diameters (e.g., GSV ≥ 3.0 mm at proximal thigh) and CEAP clinical class (C2–C6 as relevant).

Attach copies of duplex report(s) and images when available to expedite review.

Note

Authorization Triggers Not Specified in Excerpt — Verify Plan Rules

The policy excerpt does not define a single, payer-mandated prior authorization trigger or uniform step therapy sequence for all techniques; check the member's contract and plan-specific PA rules.

Some plans may require PA for specific codes or facility settings while allowing others without PA — verify per benefit.
If no explicit PA requirement is found in the excerpt, obtain plan-specific verification before scheduling procedures.

Prior Authorization

Prior Authorization Considerations for Non‑Thermal Techniques

Non‑thermal ablation methods (e.g., cyanoacrylate adhesive closure, MOCA) may require prior authorization or additional justification because evidence and guideline preference favor thermal endovenous thermal ablation (EVTA) as first-line in many cases.

When requesting PA for non‑thermal approaches, include rationale for choosing non‑thermal (anatomy, intolerance to tumescent anesthesia, prior failed thermal therapy, or device contraindication).
Provide comparative evidence and trial data when available (e.g., MOCA occlusion rates vs EVTA).

Note

FDA-Approved Devices and Agents (Informational)

Device and agent approvals are informational only and do not alone guarantee coverage. Include device/agent indication documentation when relevant to PA.

ClariVein infusion catheter (K071468) — FDA-cleared for introducing medicaments into peripheral vasculature.
VenaSeal Closure System (P140018) — FDA PMA for permanent closure of superficial truncal veins in adults with duplex-documented symptomatic venous reflux.
Varithena (polidocanol 1% microfoam) — FDA-approved for incompetent GSV, accessory saphenous veins, and visible varicosities of the GSV system.

Billing Rule

Sclerotherapy Coding and Prior Authorization Guidance

Sclerotherapy coding and PA guidance: use AMA-directed CPT codes for truncal and non‑truncal sclerotherapy and limit sessions per policy when specified.

For truncal extremity foam sclerotherapy, reference CPT 36465/36466 (non-compounded foam injection of a truncal extremity vein) when applicable per AMA guidance.
Use CPT 36470/36471 for non-truncal sclerotherapy; policy notes coverage up to three sessions per leg within a year for these codes where applicable.
If using proprietary endovenous foam (PEM/Varithena), include FDA approval and product documentation in the PA submission.

Denial Risk

Trial-Based Exclusion Signals to Anticipate

Clinical trial and study exclusion criteria used in key trials may inform candidate selection and may be requested by reviewers.

Common trial exclusion signals: BMI > 35, current anticoagulation, prior GSV treatment, CEAP class 6 (active ulcer) exclusion in some RCTs, active DVT/PE, large aneurysmal target veins (>12 mm), hypersensitivity to adhesives.
If the member meets trial exclusion characteristics, provide clinical rationale to support treatment choice and expected benefit.

Denial Risk

Evidence Limitations That May Affect Coverage

Evidence limitations exist for certain modalities (e.g., PEM, MOCA, long‑term CAE durability) and may affect coverage decisions; include available follow‑up and long‑term outcome data in submissions.

PEM (endovenous polidocanol microfoam) and MOCA have limited/low-quality long‑term evidence — submissions should include supporting studies and rationale for clinical use.
For CAE (cyanoacrylate), include longer-term follow-up data if available; small sample sizes or short follow-up in trials can increase denial risk.

Documentation Required

Governance, Training, and Audit Expectations (NICE-aligned)

Follow clinical governance, consent, training, and audit expectations per NICE and specialty guidance when performing procedures; documentation of clinician training and institutional governance may be requested.

Procedures should be performed only by clinicians with appropriate training in venous ultrasound and device use; include attestations or credentialing evidence if requested.
Maintain local audit, consent, and follow-up processes and document collection of outcome measures (e.g., VCSS, AVVQ, EQ‑5D) when feasible.

Documentation Required

Suggested Trial-Based Documentation to Include with PA

Suggested documentation elements drawn from major trials and registries can strengthen PA submissions and mirror endpoints used in studies.

Duplex-confirmed reflux measurements with numeric durations and vein diameters; pre- and post-procedure duplex reports.
Clinical severity scores and patient-reported outcomes (e.g., VCSS, AVVQ, EQ‑5D) when available.
Procedure details: device/agent used, anesthesia type (tumescent vs non-tumescent), adjunctive procedures (phlebectomy, UGFS), and follow-up schedule (day 3, 1 month, 3 months, then periodic up to available long-term data).

Billing Rule

Per-Extremity Coding Limitation and Billing Details

Clinical documentation should include planned billing details and adhere to per-extremity coding limits to avoid claim denials.

Per AMA guidance for RFA: only one primary endovenous ablation code per extremity (e.g., 36475/36478/36482/36483 for first vein) plus only one add-on code per extremity for subsequent veins (e.g., 36476/36479).
Clearly indicate laterality and list all treated veins and corresponding codes on the operative report and claim form.

Step Therapy

Step Therapy and Modality Sequencing — No Explicit Mandatory Sequence

The policy presents multiple acceptable techniques and does not impose a strict step-therapy sequence; however, guideline preference often supports a thermal‑first approach in many clinical scenarios.

No formal step therapy ordering (e.g., must fail thermal before CAE) is specified in the excerpt — include clinical justification if choosing a non‑thermal modality as first-line.
When applicable, reference guideline recommendations (EVTA preferred first-line for many patients) to support treatment choice or need for alternative technique.

Skin ulceration, frank bleeding from varicose vein, documented superficial thrombophlebitis, venous stasis dermatitis causing impairment

Use in coverage criteriaPresence of one of these impairments may be required for reconstructive treatments

Varicose Veins — definition

Varicose Veins — definitionDilated subcutaneous tributary veins >= 3 mm in diameter; corresponds to CEAP clinical class C2

Clinical featuresMay cause pain, itching, skin changes, clots, or ulcers and are assessed with CEAP classification

Diagnostic methodIdentified and measured by duplex ultrasound

Duplex Ultrasound — term and gold-standard note

Duplex Ultrasound (term) — definitionImaging modality providing anatomy and hemodynamics for diagnosis of venous insufficiency and DVT; gold standard for superficial venous incompetence

Key capabilityProvides measurements of reflux duration and vein diameter to guide treatment

Recommended practicePerform in standing or reverse Trendelenburg position for reflux assessment

Endovenous Ablation — definition (thermal and non-thermal)

Endovenous Ablation — definitionMinimally invasive closure of incompetent superficial veins using thermal (laser or radiofrequency) or non-thermal techniques (e.g., cyanoacrylate adhesive, foam sclerosant)

Technique examplesEVLA, RFA (thermal); CAE/CAC, PEM/foam (non-thermal)

Clinical useUsed to treat symptomatic axial reflux of GSV, SSV, and accessory veins when criteria met

Complete closure / anatomic success — definition

Complete closure / anatomic success — definitionDuplex-documented occlusion/absence of reflux in the target truncal vein at prespecified follow-up timepoints (e.g., 3, 12, 24, 36 months)

Assessment methodDetermined by duplex ultrasound during follow-up visits

Trial endpointsUsed as primary endpoint in pivotal RCTs (e.g., VeClose) and other studies

Recanalization / recurrent reflux — definition

Recanalization / recurrent reflux — definitionReappearance of flow or reflux in previously treated truncal veins detected by duplex, a common cause of recurrence after endovenous ablation

Clinical relevanceMajor driver of long-term anatomic failure and need for retreatment

DetectionIdentified on duplex ultrasound during follow-up assessments

CAE — definition and example

CAE (cyanoacrylate-based adhesive) — definitionEndovenous adhesive closure using cyanoacrylate glue (e.g., VenaSeal) to occlude incompetent truncal veins without tumescent anesthesia

Clinical noteUsed as a non-thermal alternative; trials report high short-to-midterm closure rates and procedural advantages

Regulatory exampleVenaSeal Sapheon Closure System referenced in pivotal trials (VeClose)

PEM — definition

PEM (polidocanol endovenous microfoam, Varithena) — definitionPharmaceutical-grade polidocanol microfoam injected under ultrasound guidance to sclerose and occlude refluxing truncal veins and tributaries

Clinical evidenceRandomized trials (VANISH, Varithena studies) showed symptom and appearance improvements versus placebo

Use caseAlternative to thermal ablation in selected anatomy or technique-limited cases

EVTA — definition

EVTA — definitionEndovenous thermal ablation (includes EVLA and RFA) — recommended as first-choice treatment for GSV and SSV incompetence per guideline statements

Clinical preferencePreferred first-line in most patients due to efficacy and recovery profile

IncludesEndovenous laser ablation and radiofrequency ablation

MOCA — definition

MOCA — definitionMechanochemical ablation combining mechanical injury (rotating wire) with liquid sclerosant infusion (ClariVein) — a non‑thermal, non‑tumescent technique

Clinical evidenceSystematic reviews show good short-term anatomical success but fewer RCTs versus EVTA; some analyses show lower occlusion versus thermal methods

Typical device exampleClariVein (K071468 referenced) used in studies

UGFS / foam sclerotherapy — definition

UGFS / foam sclerotherapy — definitionUltrasound-guided injection of sclerosant foam into varicose veins to sclerose and occlude them; used for tortuous anatomy and small trunks

Coding guidanceRefer to CPT guidance for truncal vs non-truncal injections (36465/36466 vs 36470/36471)

Evidence noteLong-term occlusion rates lower than EVTA in some meta-analyses; suitable in selected situations

CAC — definition

CAC (cyanoacrylate adhesive closure) — definitionUse of cyanoacrylate adhesive delivered endovenously to occlude pathologic veins; a non‑thermal adhesive closure technique

Example deviceVenaSeal Closure System (P140018) referenced in pivotal trials

Clinical useMay be considered when non‑thermal approach preferred or tumescent anesthesia is to be avoided

Reflux — definition

Reflux — definition>= 500 milliseconds (ms) of reversed flow in superficial truncal and selected perforating veins defines pathologic reflux

Measurement contextMeasured on duplex ultrasound in standing or reverse Trendelenburg position

Guideline sourceSVS/AVF/AVLS/SIR statements specify >500 ms cutoff

Pathologic perforating vein — definition

Pathologic perforating vein — definitionPerforating vein with outward flow duration >= 500 ms and diameter >= 3.5 mm on duplex ultrasound (in CEAP C2 patients)

Clinical relevanceAssociated with ulcers and may be targeted for ablation when criteria met

DocumentationDuplex study in standing or reverse Trendelenburg required and veins must not be secondary to acute DVT

Updated vein and procedure definitions

Updated vein & procedure definitions — included termsAccessory Vein, Great Saphenous Vein (GSV), Small Saphenous Vein (SSV), Sclerotherapy (definitions updated in policy)

Terminology alignmentPolicy aligns CEAP, duplex-based size/reflux thresholds, and updated procedure definitions

Reference noteDefinitions reflect current society guidance and were revised in policy history

Revised duplex ultrasound criteria to explicitly reference Accessory Veins and standardized requirement that studies be performed in the standing or reverse Trendelenburg position with reflux duration >= 500 ms.

2025-09-01criteria_revision

Added requirement that incompetent perforator veins not be secondary to acute deep vein thrombosis and standardized perforator reflux measurement (>= 500 ms).

2025-09-01coding_update

Removed CPT codes 37500 and 37799 from Applicable Codes and updated coding notations, including guidance to refer to CPT 36465/36466 for truncal foam sclerotherapy and clarifying coverage limits for CPT 36470/36471.

As part of recent coding updates, CPT codes 37500 and 37799 were removed from the policy's Applicable Codes list. The policy also updated coding notations to reference CPT 36465/36466 for ultrasound‑guided non‑compounded foam sclerosant procedures when performed on truncal extremity veins, and clarified the coverage limits for CPT 36470/36471.