ModifiedUnitedHealthcarePolicy CS117TN.Z

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

Medical policy governing Medicaid and CoverKids in Tennessee for surgical and ablative treatments of venous insufficiency and varicose veins, including thermal and non‑thermal ablation, sclerotherapy, ligation, and related procedures.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS117TN.Z

Change TypeCriteria and coding revisionsdefinitions added

Effective DateAugust 1, 2025

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

Replaced prior wording to expand covered treatment wording to include accessory veins and to list endovenous foam sclerotherapy and cyanoacrylate-based adhesive among treatment options considered reconstructive and medically necessary when criteria are met.

Replaced duplex ultrasound criterion wording to allow descriptions referencing Accessory Veins (>= 500 ms) as acceptable and required duplex performed in standing or reverse Trendelenburg position.

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.

Added criterion that incompetent perforator veins must not be secondary to acute deep vein thrombosis and clarified perforator reflux threshold to 500 ms or greater.

Removed CPT codes 37500 and 37799 from applicable codes and updated sclerotherapy coding guidance (use 36465/36466 where applicable; 36468 cosmetic; 36470/36471 covered up to three sessions/leg/year).

Added definitions for Superficial Vein, Telangiectasias/Spider Veins, Stab Phlebectomy, Stab Avulsion, Mini Phlebectomy, and Microphlebectomy; removed several older 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.

reflux threshold (ms)

3 mmmin GSV/SSV/accessory diameter

3.5 mmmin perforator diameter

≤3sclerotherapy sessions/leg/year

UnprovenCAE/foam for perforators

Coverage Criteria — Surgical and Ablative Procedures for Venous Insufficiency

Ablation of incompetent truncal superficial veins (GSV/SSV/Accessory)

Covered when ALL of the following are met:

Primary coverage criteria for ablation of GSV/SSV/Accessory veins: 1) Individual has one of the listed Functional or Physical Impairments: skin ulceration; frank bleeding from a varicose vein due to erosion or trauma; documented superficial thrombophlebitis; venous stasis dermatitis causing functional or physical impairment; OR moderate to severe pain causing functional or physical impairment. 2) Vein diameter: GSV ≥ 3.0 mm measured at the proximal thigh immediately below the saphenofemoral junction; SSV or Accessory veins ≥ 3.0 mm measured immediately below the appropriate junction (measured by duplex ultrasonography). 3) Duplex ultrasonography performed in the standing or reverse Trendelenburg position documents reflux ≥ 500 milliseconds for the target GSV, SSV, or Accessory vein.see node text

Duplex ultrasound interpretations describing 'moderate to severe reflux' are acceptable as equivalent to the numeric reflux threshold.

Ablation of incompetent perforator veins

Covered when ALL of the following are met:

Perforator ablation criteria: 1) Recent duplex ultrasound study performed in the standing or reverse Trendelenburg position documents perforator venous insufficiency. 2) Perforator vein diameter ≥ 3.5 mm. 3) Perforator reflux duration ≥ 500 milliseconds. 4) The perforating vein lies beneath a healed or active venous stasis ulcer (when applicable to ulcer-directed therapy). 5) The perforator insufficiency is not secondary to acute deep vein thrombosis.see node text

Ablation of perforators using endovenous foam sclerotherapy or cyanoacrylate-based adhesive is considered unproven and not medically necessary.

Ligation procedures

Proven and unproven ligation indications: - Proven/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. - Unproven/not medically necessary for 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; ligation at the saphenofemoral junction when used as an adjunct to RFA or EVLA of the main saphenous veins.

Ambulatory phlebectomy

Phlebectomy coverage note: Ambulatory phlebectomy is proven and medically necessary in certain circumstances; medical necessity clinical coverage criteria are referenced to the InterQual® CP: Procedures, Phlebectomy, Lower Extremity (Superficial Tributary Varicose Vein).see InterQual criteria

Providers must refer to the InterQual criteria for specific clinical eligibility and procedural technique guidance.

Sclerotherapy coverage

Sclerotherapy coverage constraints: Refer to applicable CPT codes for the type of sclerotherapy performed. CPT 36468 (sclerosant injections for spider veins/telangiectasias) is considered cosmetic and excluded. CPT 36470 and 36471 (sclerotherapy for non-telangiectasia/non-truncal incompetent veins) are covered up to three sessions per leg within a rolling 12-month period; more than three sessions per leg in 365 days is considered cosmetic and excluded. A session is defined as one date of service in which CPT 36470 or 36471 is performed.<=3 sessions per leg per 365 days

When truncal extremity veins are targeted with non-compounded foam and ultrasound-guided compression maneuvers, CPT 36465/36466 consideration per AMA guidance applies.

Unproven procedures

Unproven/not medically necessary procedures: Endovenous mechanochemical ablation (MOCA) of varicose veins and implantation of porcine bioprosthetic venous valves (e.g., VenoValve) for treatment of deep vein reflux are considered unproven and not medically necessary due to insufficient evidence of durable efficacy and safety.

MOCA codes (e.g., 36473/36474) are listed in coding but policy stance is unproven/not medically necessary for these indications.

Covered treatments for symptomatic venous reflux and ulcers

Covered when supported by clinical indication and evidence:

General coverage logic for symptomatic venous reflux and ulcers: Endovenous ablation (EVLA or RFA), cyanoacrylate adhesive closure, and ultrasound-guided foam sclerotherapy (PEM/Varithena) are therapeutic options for symptomatic venous reflux and varicose veins. Combined endovenous ablation plus compression therapy improves time to complete ulcer healing compared with compression alone and may be considered when duplex-confirmed reflux and clinical findings indicate eligibility. Treatment selection should be guided by anatomy, CEAP class, duplex findings, and comparative evidence of durability and complications.

Based on systematic reviews, RCTs, and guideline statements showing improved ulcer healing and symptom/QOL outcomes with appropriate interventions.

Coverage aligned to RCT inclusion criteria

Evidence from randomized controlled trials supports use when ALL of the following trial-based clinical features are documented:

Trial-aligned eligibility: 1) Symptomatic GSV incompetence with CEAP clinical class C2–C5 (trial populations commonly C2–C5). 2) Duplex ultrasound–documented GSV reflux ≥ 0.5 seconds (≥ 500 ms). 3) Target GSV diameter within trial-specified limits (e.g., aneurysm > 12 mm excluded in some trials). 4) No prior treatment of the target GSV when trials excluded previously treated veins. 5) Absence of primary SSV or AAGSV source when specifically excluded by trial protocols.

Derived from inclusion/exclusion criteria reported in pivotal RCTs such as VeClose and Alhewy et al.

Expected clinical outcomes

When authorized, clinical expectation based on trial outcomes:

Expected outcomes: High anatomic closure rates (~94–99% at 3–36 months) with EVLA, RFA, and cyanoacrylate adhesive in RCTs and cohort studies; similar improvements in symptom scores and quality of life across modalities. Cyanoacrylate tends to have less periprocedural pain, lower pigmentation and nerve injury rates, and shorter procedure times in some studies; long-term durability data extend to 60 months in select cohorts but follow-up completeness varies.

Expectations informed by VeClose RCT publications and systematic reviews/meta-analyses.

Coverage recommendations by modality

Coverage stance should reflect strength of evidence and comparative effectiveness:

Cyanoacrylate adhesive closure (CAC) for truncal veins: Randomized trials and multicenter cohorts show high short- and mid-term closure rates and symptom/QOL improvement with low serious adverse events up to 60 months; consider covered when clinical and duplex criteria for truncal reflux are met.trial follow-up up to 60 months

VeClose trial and extensions provide primary supporting evidence.

Polidocanol endovenous microfoam (PEM/Varithena): Randomized placebo-controlled trials demonstrate clinically meaningful symptom and appearance improvements; network meta-analyses do not show a statistically significant difference from EVTA for closure; consider covered for symptomatic visible varicosities meeting clinical criteria.clinical trial evidence to ~1 year and extensions

PEM evidence summarized in systematic reviews/meta-analyses.

MOCA and foam sclerotherapy for perforators:

Evidence summaries informing coverage

Summarized findings informing coverage stance:

MOCA comparative effectiveness: Systematic reviews and meta-analyses report that MOCA has lower odds of GSV closure and may show less VCSS improvement compared with RFA, EVLA, and CAC; MOCA has lower rates of nerve injury and peri-procedural pain in some analyses.

Key citations include Bontinis 2023, Lim 2023, and Hayes assessments.

Durability and evidence quality: Evidence quality and long-term durability vary by modality; MOCA and CAE/CAE alternatives have limited long-term randomized data and heterogeneity in follow-up; larger RCTs with longer follow-up are recommended to confirm durability for some devices/techniques.

Hayes assessments and Cochrane reviews highlight need for longer-term data.

VenoValve evidence: Published evidence for VenoValve is limited to very small first-in-human series (up to 11 participants) with promising short-term results but insufficient safety and durability data; device remains investigational and not FDA-approved.

Hayes Emerging Tech and early human reports summarized.

Guideline-based coverage criteria

Guideline-based recommendations for treatment of symptomatic varicose veins and related conditions

Duplex-confirmed symptomatic truncal reflux: Patient has symptomatic varicose veins or chronic venous disease with duplex ultrasound demonstrating pathologic axial or junctional reflux (reflux ≥ 500 ms) in target truncal veins (GSV, SSV, AAGSV, PAGSV).reflux >= 500 ms

Duplex ultrasound is the diagnostic test of choice per society guidance.

Treatment options for symptomatic truncal reflux: For symptomatic axial truncal reflux, thermal (EVLA, RFA) and nonthermal (MOCA, cyanoacrylate) ablation, surgical high ligation and stripping, or UGFS/PEM may be used depending on patient preference, anatomy, available expertise, and long-term outcome priorities; endovenous ablation is generally preferred over high L&S when expertise is available.

Society guidance comments on choice by vein and priority on long-term outcomes.

Perforator and ulcer-directed therapy: For patients with active or healed venous leg ulcers (C6/C5) and pathologic perforators directed to the ulcer bed (perforator reflux ≥ 500 ms and diameter ≥ 3.5 mm), ablation of incompetent superficial veins and perforator veins plus compression is suggested to aid healing and prevent recurrence.

GSV, SSV, and Accessory Veins - medically necessary when criteria met

Summary of policy history and key criteria elements:

Medically necessary treatment of GSV/SSV/Accessory veins: Initial and subsequent treatment of the GSV, SSV, and Accessory Veins with RFA, EVLA, stripping/ligation/excision, endovenous foam sclerotherapy, and/or cyanoacrylate-based adhesive are considered reconstructive and medically necessary when all listed clinical and duplex criteria are met (including duplex reflux ≥ 500 ms, standing or reverse Trendelenburg study).duplex reflux >= 500 ms

Policy revisions explicitly expanded coverage language to include Accessory veins and additional modalities when criteria are met.

Unproven / Not Medically Necessary

Not medically necessary / Unproven

Unproven treatments (policy history): Endovascular embolization of varicose veins using cyanoacrylate-based adhesive for treatment of venous reflux is designated unproven and not medically necessary in certain contexts; ablation of incompetent perforator veins using endovenous foam sclerotherapy and/or cyanoacrylate-based adhesive is also designated unproven and not medically necessary due to insufficient evidence of efficacy.

These negative stances are explicitly recorded in the policy history revisions.

Incompetent Perforator Veins - medically necessary when criteria met

Incompetent perforator veins - medically necessary when criteria met:

Ablation of incompetent perforator veins (RFA/EVLA): Ablation of incompetent perforator veins using radiofrequency ablation or endovenous laser ablation is considered reconstructive and medically necessary when all of the following are met: evidence of perforator venous insufficiency on a recent duplex ultrasound study performed in the standing or reverse Trendelenburg position; perforator reflux ≥ 500 milliseconds; perforator diameter ≥ 3.5 mm when pathologic; perforator lies beneath or is directed to an active or healed venous stasis ulcer when applicable; and the perforator insufficiency is not secondary to acute deep vein thrombosis.perforator reflux >= 500 ms; diameter >= 3.5 mm

Policy history added the requirement that perforator veins are not secondary to acute DVT and standardized duplex position requirements.

Reconstructive ablation medical necessity

Covered when ALL of the following are met:

Duplex-confirmed truncal reflux: Duplex ultrasound study performed in the standing or reverse Trendelenburg position documents duration of reflux ≥ 500 milliseconds for the GSV, SSV, or Accessory Veins.>= 500 ms

Applies to main axial and accessory superficial truncal veins.

Incompetent perforator veins (reconstructive ablation): Evidence of perforator venous insufficiency measured by a recent duplex ultrasound study performed in the standing or reverse Trendelenburg position with perforator reflux of 500 ms or greater, and documentation that the incompetent perforator veins are not secondary to acute deep vein thrombosis.>= 500 ms

Must document not secondary to acute DVT; duplex position requirement specified.

Cosmetic sclerotherapy for telangiectasias/spider veins is excluded from medically necessary coverage. CPT code 36468 is designated as cosmetic and does not correct a functional, physical, or physiological impairment. In addition, sclerotherapy sessions using CPT 36470 or 36471 are limited to up to three sessions per leg within a rolling 12‑month (365 day) period; more than three sessions per leg per year are considered cosmetic and excluded.

Treatment of spider veins/telangiectasias is considered cosmetic and is excluded from coverage. The policy specifically identifies interventions aimed at spider veins as non‑reconstructive; CPT code 36468 is noted as cosmetic and will be denied when submitted as a medically necessary service under standard benefit terms.

Endovenous ablation (radiofrequency and/or laser) of reticular or telangiectatic veins is not reconstructive and is excluded from medically necessary coverage. Ablation of these small tributary veins does not meet the policy’s reconstructive criteria and is explicitly identified as not medically necessary.

Randomized trials that inform coverage commonly excluded participants with certain characteristics. Examples of trial-based exclusions include BMI > 35, history of DVT or PE, active anticoagulation, symptomatic peripheral arterial disease, and aneurysm of the target GSV > 12 mm. These characteristics indicate situations where trial evidence may not be generalizable and should be considered operationally when reviewing prior authorization documentation.

Evidence for treating incompetent perforator veins with cyanoacrylate embolization (CAE) or endovenous foam sclerotherapy is limited and of low quality. The policy notes that peer‑reviewed literature does not yet provide robust RCT data demonstrating safety and efficacy for perforator ablation with CAE or foam; consequently these approaches are considered unproven and may not be covered or may require additional justification.

The VenoValve porcine bioprosthetic venous valve is investigational. Published human data are very limited (small early studies), and the device is not FDA‑approved; therefore VenoValve is considered investigational and not eligible for routine coverage pending further larger trials and regulatory approval.

Clinical guidance cautions against using truncal vein diameter alone to determine the need for venous ablation in symptomatic CEAP C2 patients. Diameter should not be the sole criterion for intervention; duplex‑documented reflux and clinical signs/symptoms must guide treatment decisions.

Operationally, the policy no longer asserts that ligation, subfascial or endoscopic surgery for perforator veins is categorically proven; instead, providers are directed to cross‑reference the applicable InterQual® CP modules (for example, Procedures, Phlebectomy, Lower Extremity) for specific medical necessity criteria and site‑of‑service considerations when requesting authorization for these ligation procedures.

Ablation procedures for perforator veins that are secondary to acute deep vein thrombosis (DVT) are excluded from this coverage group. The policy explicitly adds the requirement that perforator veins treated for insufficiency must not be secondary to an acute DVT.

Policy history entries in the supplied excerpts do not state additional explicit exclusions beyond those documented elsewhere in the policy; they primarily record definition and cross‑reference updates rather than new exclusion statements.

CPT code 36468 (sclerotherapy for spider veins/telangiectasias) is designated as cosmetic in the policy. This coding designation implies exclusion from coverage under the policy’s medically necessary criteria and should be considered when adjudicating claims and prior authorization requests.

The policy lists several procedures as unproven or not medically necessary for treatment of venous reflux, including stand‑alone ligation of the GSV, SSV, or accessory veins for reflux, endovenous mechanochemical ablation (MOCA) for varicose veins, and porcine bioprosthetic valve implantation (VenoValve). These procedures are identified in the policy text as having insufficient evidence to support routine coverage.

The policy explicitly states that cosmetic sclerotherapy and procedures directed at spider veins/telangiectasias are not medically necessary. CPT code 36468 is a named example of a code considered cosmetic and excluded from medical necessity coverage.

Long‑term durability and comparative effectiveness for some cyanoacrylate embolization (CAE) devices remain uncertain. Assessments and HTA summaries note limited follow‑up beyond one year in many studies and call for larger RCTs with longer follow‑up to confirm sustained benefit and comparative durability versus standard thermal techniques.

Multiple meta‑analyses and RCT syntheses report that MOCA has lower anatomic occlusion (GSV closure) rates than thermal endovenous therapies (EVLA, RFA) and may show smaller VCSS improvements in some analyses. These comparative findings support cautious coverage of MOCA and justification when MOCA is requested instead of preferred thermal techniques.

Given evidence of lower occlusion rates with MOCA in pooled RCTs and systematic reviews, the policy advises that MOCA should not be used as a first‑line alternative when EVTA (thermal endovenous therapy) is clinically appropriate. Prior authorization may require documentation supporting selection of MOCA over EVTA.

Guidelines and consensus statements recommend against routine concomitant treatment of incompetent perforating veins at the time of initial saphenous ablation in patients with CEAP class C2 disease and significant axial reflux. Perforator ablation is more appropriately considered when perforators are pathologic and directed to ulcer beds or in recurrent/residual symptomatic tributaries.

The policy designates CAE and foam sclerotherapy for perforator veins as unproven for routine perforator ablation because peer‑reviewed evidence is limited, observational, or under‑powered. As a result, these techniques may be excluded or require substantive clinical justification and prior authorization.

Ambulatory phlebectomy coverage and technique references were aligned operationally with InterQual guidance. The policy references the InterQual® CP for Phlebectomy, Lower Extremity — providers should use the InterQual criteria when requesting authorization for ambulatory phlebectomy and ensure documented technique and indications conform to that guidance.

In the supplied document chunks there are no additional explicit 'not medically necessary' statements beyond those already identified; several policy history entries reflect definition updates rather than new negative coverage determinations.

The policy reiterates the cosmetic designation of CPT 36468 for sclerosant treatment of spider veins/telangiectasias; this coding and clinical designation is repeated in the coding clarifications and policy history and should be used in adjudication and authorization processes.

Coding — Applicable Procedure and Device Codes

Applicable procedure CPT/HCPCS codesCPT

0744T	Insertion of bioprosthetic valve, open, femoral vein, including duplex ultrasound imaging guidance, when performed.
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), 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 mechanochemical ablation; first vein treated.
36474	Endovenous mechanochemical ablation; subsequent vein(s) treated in a single extremity.
36475	Endovenous ablation therapy, percutaneous, radiofrequency; first vein treated.
36476	Endovenous ablation therapy, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity.

1–10 of 22

1/3

Procedures and devices referencedmixed

not provided

Document references procedures and devices including EVLA (endovenous laser ablation), RFA (radiofrequency ablation), VenaSeal (cyanoacrylate adhesive), Varithena (polidocanol microfoam), ClariVein (mechanochemical infusion catheter), and surgical stripping/ligation, but does not list specific CPT/HCPCS codes in this section.

Coding references absent in this excerptmixed

No CPT/ICD codes listed in these chunks

The provided excerpts referenced systematic reviews and trials but did not list specific billing or diagnosis codes in these sections.

Covered CPT Codesmixed

No codes listed

Device approvals and identifiers (informational)mixed

K071468	FDA 510(k) approval number for ClariVein infusion catheter (informational).
205098	Varithena polidocanol injectable foam FDA submission identifier (informational).
P140018	VenaSeal Closure System PMA identifier (informational).

Covered/Referenced Procedures (narrative list)mixed

No codes listed

Referenced procedure guidancemixed

InterQual CP

Procedures, Phlebectomy, Lower Extremity (reference guidance).

Applicable CPT coding updates and removalsCPT

37500	CPT code removed from applicable codes.
37799	CPT code removed from applicable codes.
36465	Refer to this code 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.
36466	Refer to this code 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.
37241	Notation pertaining to this code was removed.
36468	Sclerotherapy for Spider Veins/Telangiectasias — considered cosmetic.
36470	Sclerotherapy (non-truncal, non-Telangiectasia) — covered up to three sessions per leg within a year.
36471	Sclerotherapy (non-truncal, non-Telangiectasia) — covered up to three sessions per leg within a year.

Reflux duration threshold — duplex threshold detail

Duplex reflux threshold>= 500 milliseconds (ms) measured on duplex ultrasound in the standing or reverse Trendelenburg position for GSV/SSV/Accessory veins

Acceptable report wordingDuplex interpretations describing 'moderate to severe reflux' are acceptable as equivalent to the numeric threshold

Measurement positionStanding or reverse Trendelenburg position required for duplex study

Vein diameter thresholds — GSV/SSV/accessory and perforator numeric thresholds

Truncal vein minimum diameter

Provider Actions — Authorization, Documentation, and Billing

Prior Authorization

Prior Authorization and Billing Overview

Prior authorization may be required for invasive venous procedures and select devices; verify member benefits and plan-specific PA rules before scheduling. Listing of a code in this policy does not guarantee coverage; check federal, state, and contractual requirements and current CPT guidance.

Prior authorization expectations vary by plan and state; some procedures or devices (including FDA‑approved systems) may require PA.
When InterQual criteria are referenced below, InterQual may be used operationally to adjudicate PA requests (see related callouts).

Prior Authorization

PA Required for Invasive Venous Procedures

Prior authorization is expected for invasive venous procedures such as EVTA, MOCA, CAE, endovenous foam sclerotherapy for truncal veins, and phlebectomy in many commercial and state plans. Cosmetic sclerotherapy (spider veins/telangiectasias) is excluded and should not be authorized.

Document clinical indication when submitting PA (not cosmetic).
Use current CPT guidance when selecting procedure codes to avoid coding-related denials.

Definitions and Terminology

Accessory Vein definition — venous segment ascending parallel to GSV

Accessory Vein definitionAccessory saphenous veins: venous segment ascending parallel to the GSV located more superficially above the saphenous fascia; includes anterior/posterior GSV, circumflex veins, and the Giacomini vein

Anatomic examplesIncludes anterior/posterior accessory GSV and circumflex veins; Giacomini described as cranial extension of SSV joining GSV

Reference sourcesDefinition references Lee et al., 2017 and Gloviczki et al., 2023 in the policy definitions section

Axial Reflux — uninterrupted retrograde flow definition

Axial Reflux definitionUninterrupted retrograde venous flow along the axis of a truncal vein (groin to upper calf for GSV; knee to ankle for SSV; accessory veins measured between points >=5 cm apart)

Clinical implication

Background, Evidence Summary, and Rationale

Revision History and Policy Updates

2025-08-01revisionLatest

Added reference link to Outpatient Surgical Procedures - Site of Service (Tennessee) and removed language asserting certain perforator vein surgeries as proven; directed providers to InterQual for those criteria.

revision

Replaced prior wording to expand medically necessary treatments to explicitly include Accessory Veins and to list endovenous foam sclerotherapy and cyanoacrylate-based adhesive among reconstructive options when criteria are met.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS117TN.Z

Change TypeCriteria and coding revisionsdefinitions added

Effective DateAugust 1, 2025

Next Review DateN/A

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

SourceLink

On This Page

MOCA demonstrates lower anatomic occlusion rates versus thermal ablation in multiple meta-analyses and RCTs; evidence for foam sclerotherapy of perforator veins is limited and inconsistent. Consider requiring additional justification or limiting routine coverage for these indications based on current evidence.

limited RCT and cohort data

Policies may require prior authorization or stronger documentation for these modalities.

perforator >=500 ms and >=3.5 mm

Guideline recommendation grade varies; based on SVS/AVF guidance and venous ulcer guidelines.

GSV, SSV, and Accessory veins >= 3.0 mm measured by duplex ultrasonography

Perforator vein diameterPathologic perforator veins >= 3.5 mm (policy threshold)

Varicose tributary definitionVaricose veins defined as subcutaneous tributaries >= 3 mm in diameter (CEAP C2) per definitions

GSV reflux definition in Eggen RCT — trial-specific reflux and diameter thresholds

Eggen RCT GSV reflux criterionReflux > 0.5 seconds over an intrafascial length >= 15 cm from the SFJ and GSV diameter >= 3 mm

Inclusion contextApplied to participants randomized to SFL/S vs EVLA with GSV and SFJ incompetence

Outcome assessed10-year freedom from groin recurrence reported as primary long-term outcome

Duplex reflux threshold — trial inclusion threshold (>= 0.5 seconds)

Trial inclusion duplex threshold>= 0.5 seconds (>= 500 ms) reflux on duplex ultrasound used as inclusion criterion in multiple RCTs (e.g., Alhewy 2024, VeClose)

CEAP classes in trialsTrials commonly enrolled symptomatic participants with CEAP C2–C5

Duplex measurement methodReflux measured by duplex ultrasound per trial protocols (standing or as specified)

Target GSV aneurysm size exclusion — trial exclusion (>12 mm)

GSV aneurysm exclusion> 12 mm aneurysm of target GSV excluded in Alhewy 2024 trial

Other trial exclusionsTrials excluded prior GSV treatment, symptomatic PAD, BMI >35, active anticoagulation, and CEAP class 6 in some studies

RationaleLarge aneurysmal target veins may have been excluded due to anatomic/technical considerations in RCTs

Follow-up duration reported — longest follow-up in trials (up to 60 months)

Longest reported follow-upUp to 60 months follow-up reported in VeClose extension publications (Morrison et al.)

Common follow-up intervalsTrials reported outcomes at day 3, 1, 3, 6, 12, 24, 36 months and some extensions to 60 months

Endpoints usedComplete vein closure on duplex, VCSS, AVVQ and EQ-5D QOL measures reported at follow-up visits

Reflux duration — duplex threshold repeated

Policy duplex reflux threshold (reiteration)>= 500 milliseconds (ms) for GSV, SSV, or Accessory Veins measured on duplex in standing or reverse Trendelenburg

Acceptable wordingDuplex reports stating 'moderate to severe reflux' accepted as equivalent to numeric threshold

Applies toMain truncal and accessory superficial veins per revised coverage criteria

Pathologic perforator diameter — numeric threshold

Pathologic perforator diameter threshold>= 3.5 mm on duplex ultrasound for pathologic perforator veins

Associated reflux requirementPerforator reflux duration >= 500 ms required in policy when pathologic

Clinical contextPathologic perforators defined for CEAP C2 patients and considered when directed to ulcer bed for higher CEAP classes

Duplex reflux duration — policy duplex threshold reiteration

Policy duplex reflux duration (formal)>= 500 milliseconds (ms) measured on duplex ultrasound in standing or reverse Trendelenburg for truncal and perforating veins

Documentation requirementDuplex study must document duration of reflux (>=500 ms) and be performed in standing or reverse Trendelenburg position

Perforator veins notePerforator veins must also be documented as not secondary to acute deep vein thrombosis

Duplex reflux duration — policy duplex threshold reiteration (duplicate chunk set)

Duplex reflux duration (policy repeat)>= 500 milliseconds (ms) for GSV/SSV/Accessory and perforating veins (policy-standardized threshold)

Policy historyRevised coverage criteria explicitly replaced 'principal tributaries' with 'Accessory Veins' and standardized the reflux threshold wording

Measurement positionStudy must be performed standing or in reverse Trendelenburg

Sclerotherapy session limit — up to 3 sessions per leg/year for CPT 36470/36471

Sclerotherapy sessions limitCPT 36470 and 36471: covered up to three sessions per leg within a rolling 12-month period

CPT 36468 statusCPT 36468 (sclerotherapy for spider veins/telangiectasias) is considered cosmetic and excluded

Coding guidanceRefer to CPT 36465/36466 per AMA guidance when non-compounded foam sclerosant with ultrasound compression is used for extremity truncal veins

Documentation Required

Clinical Eligibility Evidence Required

Clinical eligibility evidence should be submitted with authorization requests. Requests lacking objective diagnostic imaging or trial-like documentation may be denied or delayed.

Include CEAP clinical class and VCSS where applicable.
Include a recent duplex ultrasound report with measurements (vein diameter, reflux duration) and study position.
Document prior conservative treatments and dates (e.g., compression, compression trial).

Prior Authorization

PA for Limited‑Evidence Procedures (MOCA, CAE/foam for Perforators)

For limited-evidence procedures (e.g., MOCA; cyanoacrylate or foam for perforator veins), prior authorization should require justification and stronger supporting documentation due to uncertain/limited evidence of efficacy.

Explain rationale for choosing limited‑evidence treatment vs guideline‑preferred EVTA.
Provide relevant literature, prior treatment failures, or contraindications to standard therapies.
Note that MOCA has demonstrated lower occlusion rates versus EVTA in meta-analyses and may drive denials without strong justification.

Prior Authorization

Device‑Related Prior Authorization

When device-specific products are used, indicate device name and FDA status in the authorization request. Devices with FDA approval/clearance should be documented; investigational devices may affect coverage.

Document device model (e.g., VenaSeal, ClariVein, Varithena) and include FDA approval/PMA/K-number if available.
If using non‑FDA approved or investigational devices, include protocol/IDE information and rationale.

Note

Prior Authorization — InterQual Cross‑Reference

InterQual criteria may be applied operationally for some procedures; when InterQual is referenced in the policy, include any required InterQual documentation elements with the PA submission.

Specifically, InterQual Procedures: Phlebectomy, Lower Extremity may be referenced for ambulatory phlebectomy determinations.
If InterQual criteria are used, note the InterQual version/date and relevant decision nodes in the request.

Note

Policy History and Operational Impact on PA

Policy history includes multiple revisions that affect coverage rationale, definitions, code lists, and references to InterQual; these history entries may influence operational PA decisions but do not replace plan‑specific benefit language.

Recent changes removed or added references to InterQual and updated duplex criteria and perforator vein thresholds.
Definitions were added/updated (e.g., phlebectomy variants) and CPT codes were removed or reclassified; confirm current code lists before submitting PA.

Note

Verify Prior Authorization per Plan

Some excerpts in the policy do not explicitly state authorization requirements; absence of a PA statement in the policy does not mean PA is not required by the member's plan. Always verify PA requirements per the member's contract.

Contact the member's plan/portal for current PA rules.
Check state‑specific mandates and federal/contractual exceptions that may override standard PA processes.

Documentation Required

Required Diagnostic Imaging and Clinical Documentation

Providers must document diagnostic imaging and clinical outcome measures to support medical necessity determinations. Incomplete or improperly performed duplex studies are a common cause of denials.

Duplex ultrasound study must be performed in standing or reverse Trendelenburg position and include reflux duration (ms) and vein diameters.
For truncal veins (GSV, SSV, Accessory): document diameter ≥ 3.0 mm and reflux duration ≥ 500 ms where applicable.
For perforator veins: document diameter ≥ 3.5 mm, reflux ≥ 500 ms, and relationship to healed/active venous stasis ulcer when claimed.
Provide baseline CEAP class and VCSS and post-procedure follow-up imaging and clinical scores when available (duplex occlusion, VCSS, CEAP, AVVQ/EQ-5D).

Note

Potential Clinical Eligibility Exclusions Referenced in Trials

Potential clinical eligibility exclusions and trial exclusion criteria from pivotal studies (e.g., BMI limits, prior treatments, DVT history, device sensitivities) may inform authorization decisions; include relevant contraindications or exclusions in the request.

Trials excluded patients with prior GSV treatment, active anticoagulation, recent DVT/PE, large aneurysmal target veins, or BMI thresholds; note these where relevant to clinical comparability.
Cyanoacrylate or foam for perforator veins is considered unproven — include rationale if requesting coverage.

Denial Risk

MOCA — Efficacy Considerations That May Affect Authorization

MOCA has shown lower anatomical occlusion rates versus EVTA in some meta-analyses and RCTs; when requesting MOCA, document why EVTA is not appropriate and provide outcome expectations and follow-up plans.

Compare prior outcomes or anatomic constraints that preclude EVTA (e.g., tortuous anatomy).
Provide plan for follow-up duplex surveillance and criteria for reintervention.

Note

Treatment Selection and Sequencing

When requesting authorization for procedures that are guideline‑preferred sequenced (e.g., EVTA before non‑thermal techniques), document the treatment selection rationale.

If non‑thermal or limited‑evidence modalities are proposed first, include contraindications to EVTA or other justification.
Document prior conservative management and any anatomical limitations to EVTA.

Axial reflux indicates continuous retrograde flow and is used to identify target truncal incompetence

Guideline concordanceDefinition aligns with SVS/AVF/AVLS/SIR statements that axial reflux is uninterrupted retrograde flow from groin to calf

Moderate to Severe Pain (VCSS) definition

Moderate to Severe Pain (VCSS)Moderate pain: daily pain interfering with but not preventing activities; Severe pain: daily pain limiting most regular activities (VCSS definitions)

Use in criteriaModerate to severe pain causing functional/physical impairment is an acceptable indication for ablation when documented

Scoring toolVCSS referenced as the instrument defining pain severity categories

Endovenous ablation (EVTA) definition

Endovenous ablation (EVTA)Therapies using laser or radiofrequency energy to create heat and close varicose veins (per policy definitions)

Modalities includedEVLA and RFA described as thermal EVTA options; compared against nonthermal techniques in evidence summaries

Clinical noteEVTA is recommended as first-line in guidelines for symptomatic truncal reflux when available

Cyanoacrylate adhesive closure definition

Cyanoacrylate adhesive closure (CAC)Non‑thermal, non‑sclerosant endovascular embolization using medical adhesive (e.g., VenaSeal) to close superficial truncal veins without tumescent anesthesia

Trial evidenceCAC evaluated in randomized trials (VeClose) with mid‑ to long‑term closure data reported up to 60 months

Practical notesCAC does not require tumescent anesthesia and may have shorter procedure times and less periprocedural pain in some trials

Ultrasound-guided foam sclerotherapy (UGFS) definition

Ultrasound-guided foam sclerotherapy (UGFS)Injection of polidocanol microfoam (PEM/Varithena) under ultrasound to damage endothelium causing scarring and occlusion (e.g., Varithena)

Evidence summaryRandomized placebo-controlled trials demonstrate symptom and appearance improvement versus placebo; network meta-analyses compare PEM with EVTA

Coding guidancePolicy includes instructions to refer to CPT 36465/36466 per AMA when non-compounded foam with ultrasound compression is used

MOCA definition — mechanochemical ablation description

MOCA (mechanochemical ablation)Catheter-based technique combining mechanical endothelial injury (rotating wire) with local sclerosant infusion (e.g., ClariVein) to produce vein occlusion

Efficacy caveatSystematic reviews and RCT meta-analyses report lower GSV closure and VCSS improvement for MOCA versus thermal ablation

Safety profileMOCA associated with lower peri-procedural nerve injury and less postprocedural pain in some studies

Complete vein closure — definition used in trials and follow-up

Complete vein closureAnatomic occlusion of the target GSV as assessed by duplex ultrasound at specified follow-up time points (commonly 3, 12, 24, 36 months); used as primary endpoint in VeClose and other trials

Assessment methodsDuplex ultrasound used to determine complete closure at follow-up visits

Trial contextVeClose used complete closure at 3 months as primary endpoint with serial follow-up to 60 months in extensions

CAC/CAE definition — cyanoacrylate closure/embolization description

CAC/CAE descriptionEndovenous cyanoacrylate adhesive closure/embolization uses medical adhesive to occlude incompetent truncal veins without tumescent anesthesia (e.g., VenaSeal)

Trial evidenceEvaluated in RCTs (VeClose, Alhewy) demonstrating high closure rates and symptom/QOL improvements; policy notes some concerns about long-term comparative data for some devices

Policy stance notePolicy history revised wording to include CAC among reconstructive/medically necessary options when criteria met, but also identifies some CAE uses as unproven in specific contexts

CAC/CAE/VenaSeal — definition and trial context

CAC/CAE/VenaSeal contextVenaSeal closure system evaluated in VeClose RCT with multiple publications reporting 3‑ to 60‑month outcomes showing high closure rates and sustained symptom/QOL improvement

Regulatory noteVenaSeal has a PMA (P140018) per policy references (informational) and is included in device discussion

Procedure characteristicsCAC does not require tumescent anesthesia and may allow faster procedures with different adverse event profiles compared with RFA/EVLA

PEM / Varithena definition and context

PEM / VarithenaPharmaceutical-grade polidocanol 1% endovenous microfoam (Varithena) used for symptomatic varicose veins; randomized trials demonstrate symptom and appearance improvements versus placebo

Comparative evidenceNetwork meta-analyses show PEM not statistically different from EVTA for closure in some analyses; longer head-to-head trials limited

Intended useUsed for visible varicosities and symptomatic superficial venous incompetence often as adjunct or alternative to other therapies

MOCA definition in evidence context (lower efficacy findings)

MOCA evidence contextSystematic reviews/meta-analyses indicate MOCA has lower odds of GSV closure and less VCSS improvement compared with RFA, EVLA, and CAC

Registry and RCT dataPooled analyses and registries report anatomic success rates around 87–92% short- to mid-term with variable longer-term recanalization

Coverage implicationPolicy notes MOCA may be considered inferior and may affect medical necessity determinations relative to EVTA

MOCA procedural description (ClariVein example)

MOCA procedural description (ClariVein example)Uses a flexible steerable infusion catheter with a rotatable dispersion wire to cause mechanical endothelial damage followed by sclerosant infusion to induce sclerosis and occlusion

Device exampleClariVein infusion catheter described in policy device section (informational, K071468) as an example of MOCA delivery

Technical noteMOCA is non-thermal and typically performed without tumescent anesthesia

VenoValve — investigational porcine bioprosthetic valve description

VenoValve descriptionInvestigational porcine bioprosthetic venous valve implanted into femoral vein to restore valve function for chronic venous insufficiency (early human data only)

Regulatory statusDevice is investigational and not FDA‑approved at time of policy; small early human series reported

Evidence limitationPublished studies are very small (up to 11 participants) with limited safety and durability data

Reflux — numeric duplex threshold (>= 500 ms)

Reflux numeric threshold>= 500 ms (0.5 seconds) of reversed flow on duplex ultrasound for superficial truncal and perforating veins

Measurement positionMeasured in standing or reverse Trendelenburg position per policy and guideline statements

Guideline sourceSVS/AVF/AVLS/SIR definitions endorse >500 ms as reflux threshold for superficial veins and perforators

Axial Reflux — directional flow definition reiterated

Axial reflux (reiterated)Directional uninterrupted retrograde flow from groin to calf defines axial reflux and is used to identify target truncal incompetence

Measurement implicationsAxial reflux assessment helps differentiate junctional versus axial disease for treatment planning

Policy alignmentDefinition consistent with policy's use of axial reflux in coverage logic

Pathologic perforating vein — diameter and reflux thresholds

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

Clinical applicationPathologic perforators considered for ablation when directed to an ulcer bed or when meeting specified size/reflux thresholds

Documentation requirementDuplex performed standing or reverse Trendelenburg and documentation that perforator is not secondary to acute DVT (policy revision)

CEAP classification reference

CEAP referenceClinical‑Etiology‑Anatomic‑Pathophysiologic (CEAP) classification referenced for staging chronic venous disorders (2020 update)

Common CEAP classes usedPolicy references CEAP classes C2–C6 for clinical severity in trials and coverage criteria

Use in trialsCEAP class used to define eligibility and interpret outcomes in RCTs cited (e.g., VeClose, Alhewy)

Duplex ultrasound reflux threshold — standing or reverse Trendelenburg measurement

Duplex ultrasound measurement positionStanding or reverse Trendelenburg position required for duplex studies used to document reflux duration

Threshold reiterated>= 500 ms for reflux duration as policy threshold applied to GSV/SSV/Accessory/Perforating veins

Reporting noteDuplex reports may substitute descriptive terms (eg, moderate to severe reflux) for numeric values when appropriate

Superficial Vein / Telangiectasias/Spider Veins / Stab Phlebectomy definitions added

Superficial Vein definition (policy added)Veins located above the muscular fascia; definition added to policy's Definitions section

Telangiectasias/Spider Veins definitionDilated small superficial veins <1 mm in diameter predominantly in lower extremities; definition added to policy

Stab Phlebectomy and related definitionsDefinitions for Stab Phlebectomy, Stab Avulsion, Mini/Micro Phlebectomy added to policy history

Stab Phlebectomy — definition added

Stab Phlebectomy definition addedPolicy history shows Stab Phlebectomy and related procedure definitions (Stab Avulsion, Mini Phlebectomy, Microphlebectomy) were added to the Definitions section

Operational noteThese definition additions clarify terminology used for ambulatory phlebectomy and related coding

Reference to InterQualPolicy references InterQual CP for detailed phlebectomy medical necessity criteria

Policy history — multiple definitions added and removed

Definitions added/removed summaryPolicy history: added definitions for Superficial Vein, Telangiectasias/Spider Veins, Mini/Micro Phlebectomy, Stab Avulsion/Phlebectomy; removed definitions for Cosmetic Procedures, Reconstructive Procedures, Reticular Vein, Spider Vein, and Superficial Thrombophlebitis

Coding updates linkedPolicy history concurrently updated coding guidance and removed CPT codes 37500 and 37799

Documentation implicationProviders should use updated definitions when documenting procedures and indications

revision

Revised duplex ultrasound criterion wording to specify that studies performed in the standing or reverse Trendelenburg position documenting reflux ≥500 ms apply to GSV, SSV, and Accessory Veins and clarified perforator reflux wording to 500 ms or greater.

revision

Added criterion that incompetent perforator veins must not be secondary to acute deep vein thrombosis and standardized duplex study position requirement.

revision

Updated coding: removed CPT codes 37500 and 37799; clarified sclerotherapy coding and limits (36468 cosmetic for spider veins; 36470/36471 covered up to three sessions per leg per year) and added instruction to refer to CPT 36465/36466 per AMA guidance when appropriate.