ModifiedUnitedHealthcarePolicy CS117TN.Z

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

Medical policy governing coverage and medical necessity criteria for surgical and endovenous treatments of venous insufficiency and varicose veins for Tennessee Medicaid and CoverKids members.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS117TN.Z

Change TypeRevised coverage criteria and added/removed definitionsmaterial changes to duplex requirements and treatment designations

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionObtain and include a recent standing or reverse Trendelenburg duplex ultrasound showing reflux >=500 ms and required vein diameters to support prior authorization.

SourceLink

POLICY UPDATE CHANGES

Added reference link to the Medical Policy titled Outpatient Surgical Procedures - Site of Service (for Tennessee Only).

Replaced language to expand the list of acceptable treatments for GSV, SSV, and accessory veins to include endovenous foam sclerotherapy and cyanoacrylate-based adhesive and adjusted duplex ultrasound wording to reference Accessory Veins (>=500 ms).

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

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

Added requirement that incompetent perforator veins are not secondary to acute deep vein thrombosis and specified duplex ultrasound standing/reverse Trendelenburg requirement with reflux >= 500 ms for perforator veins.

Added criterion requiring that incompetent perforator veins are not secondary to acute deep vein thrombosis.

Replaced requirement for 'Duplex Ultrasonography report' with 'duplex ultrasound study performed in the standing or reverse Trendelenburg position'.

Clarified reflux threshold language to 'duration of reflux that is greater than or equal to 500 milliseconds (ms)' for GSV, SSV, accessory veins and perforating veins.

Added reference to InterQual CP: Procedures, Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein and removed references to the Ambulatory Phlebectomy Varicose Vein InterQual CP for specific procedure names.

Added multiple definitions including 'Superficial Vein', 'Telangiectasias/Spider Veins', and 'Tributary Vein'.

Added definitions for 'Superficial Vein', 'Telangiectasias/Spider Veins', 'Tributary Vein', and 'Stab Phlebectomy'.

Added definition(s) for Superficial Vein, Stab Phlebectomy, Stab Avulsion, and Mini Phlebectomy.

Removed definitions for Cosmetic Procedures, Reconstructive Procedures, Reticular Vein, Spider Vein, and Superficial Thrombophlebitis.

Updated definitions for Accessory Vein, Great Saphenous Vein, Sclerotherapy, and Small Saphenous Vein.

Removed CPT codes 37500 and 37799 from applicable codes.

Changed coverage/coding instructions: refer to CPT 36465 or 36466 per AMA guidance for targeted extremity truncal vein injections of non-compounded foam sclerosant with ultrasound guided compression maneuvers.

Removed notation pertaining to CPT code 37241 and revised which sclerosclerosis CPTs are considered cosmetic or covered (36468 cosmetic for Spider Veins/Telangiectasias; 36470 and 36471 covered for non-truncal, non-Telangiectasia up to three sessions per leg per year).

Updated Supporting Information sections including Description of Services, Clinical Evidence, FDA, and References.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

3 mmGSV/SSV/accessory min diameter

>=500 msDuplex reflux threshold

3.5 mmPerforator min diameter

<=3/leg/yrSclerotherapy session limit

2CPT codes removed

TennesseeGeographic applicability

Coverage and Medical Necessity Criteria

inv-01: Thermal and Non-Thermal Treatments (GSV/SSV/Accessory)

Thermal and Non-Thermal Treatments for Venous Insufficiency and Varicose Veins — Covered when ALL of the following are met:

ALL of the following

Individual has one of the following functional or physical impairments: skin ulceration; documented episode(s) of frank bleeding of the varicose vein due to erosion of 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.
Venous size: the Great Saphenous Vein (GSV) measures >= 3.0 mm when measured at the proximal thigh immediately below the saphenofemoral junction by duplex ultrasonography; or the Small Saphenous Vein (SSV) or accessory veins measure >= 3.0 mm in diameter immediately below the appropriate junction by duplex ultrasonography.
Duplex ultrasound study performed in the standing or reverse Trendelenburg position demonstrates duration of reflux >= 500 milliseconds for the GSV, SSV, or accessory veins (duplex interpretations describing 'moderate to severe reflux' are acceptable).
Treatment is one or more of the following: radiofrequency ablation (RFA), endovenous laser ablation (EVLA), stripping with ligation and excision, endovenous foam sclerotherapy (PEM), and/or cyanoacrylate-based adhesive (CAE) for initial or subsequent treatment of GSV, SSV, or accessory veins.
Procedures intended to treat spider veins/telangiectasias (including CPT 36468) are considered cosmetic and are excluded from coverage.

inv-02: Perforator Vein Ablation

Perforator Vein Ablation — Reconstructive and medically necessary when ALL of the following are met:

ALL of the following

Evidence of perforator venous insufficiency measured by a recent duplex ultrasound study performed in the standing or reverse Trendelenburg position.
Perforator vein size is >= 3.5 mm in diameter.
Perforating vein reflux duration is >= 500 milliseconds.
Perforating vein lies beneath a healed or active venous stasis ulcer or is directed toward the area of skin change/ulceration.
Not secondary to acute deep vein thrombosis.

inv-03: Unproven / Not Medically Necessary Procedures

Unproven / Not Medically Necessary Procedures — The following interventions are considered unproven and not medically necessary for treating venous reflux due to insufficient evidence of efficacy:

ANY of the following

Endovenous mechanochemical ablation (MOCA) of varicose veins.
Endovascular embolization of varicose veins using cyanoacrylate-based adhesive for indications where long-term efficacy versus established techniques is unproven (CAE for perforator veins and certain other indications).
Ablation of incompetent perforator veins using endovenous foam sclerotherapy and/or cyanoacrylate-based adhesive.
Porcine bioprosthetic valve implantation (e.g., VenoValve) into the femoral vein for treatment of deep vein reflux associated with chronic venous insufficiency.

inv-04: Ambulatory Phlebectomy

Ambulatory Phlebectomy — Coverage stance:

ALL of the following

Ambulatory phlebectomy for treatment of varicose veins is considered reconstructive and medically necessary in certain circumstances when clinical criteria are met; medical necessity clinical coverage criteria refer to InterQual® CP: Procedures, Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein (link provided in policy).

inv-05: Exclusions / Evidence-supported indications

Exclusions and evidence-supported indications — explicit exclusions and key supported indications:

ALL of the following

Treatments for spider veins and/or telangiectasias (including sclerotherapy for telangiectasias, CPT 36468) are considered cosmetic and excluded from coverage.
Endovenous ablation (radiofrequency and/or laser) of reticular or telangiectatic veins is not reconstructive and is excluded from coverage.
Sclerotherapy: cosmetic sclerotherapy is excluded; CPT codes 36470 and 36471 are covered for non-truncal sclerotherapy up to three sessions per leg within a rolling 12-month period; more than three sessions per leg in 12 months is considered cosmetic and excluded.
Ablation combined with compression therapy is supported by evidence for improved ulcer healing and is an accepted indication for individuals with venous leg ulcers when criteria (e.g., reflux directed to ulcer bed, pathologic perforators) are met (Cochrane and guideline evidence summarized in policy).

inv-06: Trial-derived candidate and documentation criteria

Trial-derived candidate and documentation criteria — Coverage when ALL trial-supported conditions and documentation requirements are met:

ALL of the following

Documentation of symptoms and functional/physical impairment attributable to venous insufficiency (e.g., pain limiting activities, dermatitis, ulceration).
Recent duplex ultrasonography report performed in standing or reverse Trendelenburg position documenting reflux parameters, vein diameters, and vein segments evaluated.
For truncal vein ablation, reflux duration >= 500 ms and target vein diameter criteria as specified (GSV/SSV/accessory >= 3.0 mm; perforator >= 3.5 mm).
Prior conservative management (compression therapy, leg elevation, topical care, and when appropriate, trial of medical therapy) should be documented unless contraindicated by the severity of disease (e.g., active ulceration requiring prompt intervention).

Procedure Codes, Diagnostic Thresholds, and Coding Notes

Covered CPT CodesCPTCovered

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
36470	Injection of sclerosant; single incompetent vein (other than telangiectasia)
36471	Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg
36473	Endovenous ablation therapy, mechanochemical; first vein treated
36474	Endovenous ablation therapy, mechanochemical; subsequent vein(s) treated in a single extremity
36475	Endovenous ablation therapy, radiofrequency; first vein treated
36476	Endovenous ablation therapy, radiofrequency; subsequent vein(s) treated in a single extremity
36478	Endovenous ablation therapy, laser; first vein treated
36479	Endovenous ablation therapy, laser; subsequent vein(s) treated in a single extremity

1–10 of 20

1/2

Procedures described (single-code descriptors)mixed

36482	Endovenous ablation therapy of incompetent vein by transcatheter delivery of a chemical adhesive (e.g., cyanoacrylate) — VenaSeal (cyanoacrylate closure) referenced
Varithena	Polidocanol injectable foam (proprietary Varithena) referenced as polidocanol endovenous microfoam (PEM) — coded via 36465/36466 when foam sclerosant with ultrasound compression maneuvers used

Removed CPT CodesCPTNot Covered

37500	Removed from applicable codes
37799	Removed from applicable codes

Sclerotherapy CPT Codes and NotesCPT

36465	Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate; single incompetent extremity truncal vein — use when targeted extremity truncal vein treated with non-compounded foam and ultrasound-guided compression maneuvers
36466	Injection of non-compounded foam sclerosant with ultrasound compression maneuvers; multiple incompetent truncal veins, same leg
36470	Injection of sclerosant; single incompetent vein (other than telangiectasia) — covered up to three sessions per leg per 12 months (rolling)
36471	Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg — covered up to three sessions per leg per 12 months (rolling)

FDA device approvals citedmixed

ClariVein (K071468)	ClariVein infusion catheter FDA approval referenced
VenaSeal (P140018)	VenaSeal Closure System PMA approval referenced
Varithena (polidocanol injectable foam)	Varithena FDA approval Nov 25, 2013 referenced as polidocanol microfoam (PEM)

Pharmaceutical/Agent approvalsmixed

Asclera (polidocanol)	Asclera polidocanol approval March 2010 referenced for small spider veins/reticular veins
Varithena (polidocanol injectable foam)	Varithena approval referenced for incompetent GSVs, accessory saphenous veins and visible varicosities of the GSV system

Reflux duration (superficial/perforator) — numeric threshold

Reflux duration (superficial/perforator)>= 500 ms

Vein diameter (GSV/SSV/accessory) — numeric threshold

Vein diameter (GSV/SSV/accessory)>= 3 mm

Perforator vein diameter — numeric threshold for ablation

Perforator vein diameter>= 3.5 mm

Sclerotherapy session limit — <= 3 sessions per leg per 12 months (rolling)

Sclerotherapy session limit

Prior Authorization, Documentation, and Operational Guidance

Prior Authorization

Reference codes listed — prior authorization may apply

The policy includes a reference list of procedure codes for provider and billing reference; inclusion does not guarantee coverage and codes may be subject to state/contractual prior authorization requirements.

Refer to the policy's Applicable Codes table for CPT codes such as 36465, 36466, 36468, 36470, 36471, 36473–36483, 37700–37785, and 0744T when preparing authorizations and claims.
Listing of a code does not imply coverage—benefit coverage is determined by federal, state, or contractual requirements.

Prior Authorization

Obtain prior authorization to establish medical necessity — cosmetic exclusions must be documented

Prior authorization should be obtained to establish medical necessity and to document that the proposed procedure is not an excluded cosmetic treatment (e.g., cosmetic sclerotherapy or therapy for spider veins/telangiectasias).

Cosmetic sclerotherapy and treatments for spider veins/telangiectasias are excluded from coverage; authorization must differentiate cosmetic from reconstructive indications.

Clinical Background and Evidence Summary

Varicose veins result from venous valve failure leading to retrograde flow (reflux) and venous pooling. Clinical consequences range from cosmetic concerns to functional or physical impairments such as pain, superficial thrombophlebitis, bleeding from eroded varicosities, venous stasis dermatitis, and ulceration. Duplex ultrasonography performed in the standing or reverse Trendelenburg position is the diagnostic standard to document reflux and guide management decisions.

Key randomized trials, registries, and systematic reviews inform the policy. The VeClose randomized trial and its 3‑ to 60‑month follow-ups report high early and mid‑term GSV closure rates with cyanoacrylate closure (CAC) comparable to RFA, though long‑term follow-up is limited by attrition. Systematic reviews and meta‑analyses (including Amshar et al. and Dimech & Cassar) report similar one‑year closure rates and fewer procedural pain and pigmentation events with CAE versus thermal ablation but note the need for larger, longer randomized studies. For foam sclerotherapy (PEM/Varithena), RCTs and meta‑analyses demonstrate symptom and appearance improvements versus placebo and comparable short‑term closure to some modalities, while MOCA meta-analyses show lower occlusion rates versus EVTA at one year; overall, evidence strength and duration vary across modalities.

Clinical guidelines and evidence syntheses support preferential use of endovenous thermal ablation (EVTA) as first‑line treatment for symptomatic GSV and SSV incompetence, with ultrasound‑guided foam sclerotherapy (UGFS/PEM), cyanoacrylate closure (CAC), or MOCA considered in selected situations. Guidelines note UGFS may be appropriate for saphenous trunks < 6 mm or tortuous anatomy; CAC and MOCA are options when a non‑thermal approach is preferred, but randomized and long‑term comparative data remain limited and inform the policy’s cautious stance on newer techniques for certain indications.

Definitions and Terminology

Accessory Vein definition

Accessory Vein (policy definition)A superficial venous segment ascending parallel to the GSV and located above the saphenous fascia; includes anterior/posterior accessory GSVs and circumflex veins.

Typical examples notedMay include the vein of Giacomini (cranial extension of SSV) joining the GSV.

Moderate to Severe Pain — VCSS-based definitions

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

Duplex Ultrasonography — definition and positioning note

Duplex Ultrasonography (definition)

Reference and Operational Notes for Providers

Note

Reference federal/state/contractual requirements when authorizing

Reviewers must reference federal, state, or contractual benefit plan requirements when making coverage decisions because those requirements govern in the event of conflict with this policy.

Before authorizing, verify applicable federal, state, or contract-specific coverage mandates that may override standard policy determinations.
Document any contractual coverage provisions relied upon in the authorization determination.

Prior Authorization

Use InterQual phlebectomy CP for ambulatory phlebectomy prior authorization

For prior authorization of phlebectomy procedures, reference the updated InterQual CP: Procedures, Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein as the external criteria to guide medical necessity determinations.

Use the InterQual phlebectomy criteria to document indications and to support the authorization decision for ambulatory phlebectomy.
The policy removed older Ambulatory Phlebectomy InterQual references—use the newly referenced InterQual CP.

Policy Update Changes

2025-08-01related_policy_updateLatest

Added reference link to the Medical Policy titled 'Outpatient Surgical Procedures - Site of Service (for Tennessee Only)' and removed language regarding ligation, subfascial, endoscopic surgery for perforating veins from coverage rationale.

coverage_revised

Replaced prior language to explicitly include endovenous foam sclerotherapy and cyanoacrylate-based adhesive among acceptable treatments for GSV, SSV, and accessory veins when listed criteria are met; clarified duplex interpretation language to reference accessory veins and acceptable reflux thresholds.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS117TN.Z

Change TypeRevised coverage criteria and added/removed definitionsmaterial changes to duplex requirements and treatment designations

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionObtain and include a recent standing or reverse Trendelenburg duplex ultrasound showing reflux >=500 ms and required vein diameters to support prior authorization.

SourceLink

On This Page

Ablation using radiofrequency ablation or endovenous laser ablation (EVLA) is the preferred covered technique; 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.

Standalone ligation of the GSV, SSV, or accessory veins (as unproven for treating venous reflux), and ligation at the saphenofemoral junction when used as an adjunct to endovenous ablation of the main saphenous veins.

Procedure reports and follow-up documentation should note adjunctive treatments performed (phlebectomy, UGFS) and clinical outcomes; when using CAE, informed consent should include discussion of the current evidence base and alternatives.

<= 3 sessions per leg per 12 months (rolling)

GSV reflux definition used in RCT inclusion — reflux >0.5 sec, intrafascial length >=15 cm, diameter thresholds

GSV reflux definition used in RCT inclusionreflux >0.5 sec; intrafascial length >=15 cm; GSV diameter >=3 mm and <=15 mm

Maximum BMI exclusion in trial — BMI > 35 exclusion

Maximum BMI exclusion in trialBMI > 35 exclusion

Sclerotherapy sessions per leg — up to three sessions per leg within a year (operational summary)

Sclerotherapy sessions per legUp to three sessions per leg within a rolling 12-month period (365 days)

Obtain authorization to document clinical impairment (ulceration, bleeding, thrombophlebitis, venous stasis dermatitis, or moderate–severe pain) when seeking coverage for reconstructive procedures.

Prior Authorization

Require duplex confirmation and documentation of exclusion criteria with authorization

Authorization requests must include duplex ultrasound confirmation of venous insufficiency and documentation showing exclusion of trial-based disqualifiers (e.g., prior target vein treatment, relevant anatomic exclusion).

Provide a recent duplex ultrasound performed standing or in reverse Trendelenburg documenting reflux duration (≥500 ms) and vein diameter thresholds (e.g., GSV/SSV/accessory ≥3 mm).
Report patient factors mirroring trial exclusions as relevant (prior GSV treatment, significant SSV/AAGSV reflux, BMI limits, active anticoagulation, CEAP class 6) to support candidacy.

Prior Authorization

Seek prior authorization for CAC (VenaSeal) or PEM (Varithena) procedures — provide evidentiary support

Prior authorization is recommended when proposing cyanoacrylate closure (CAC/CAE) or polidocanol endovenous microfoam (PEM) because the evidence base and coverage stance vary and supporting documentation is needed.

Include indication, prior conservative therapy, target vein(s), duplex imaging showing reflux ≥500 ms, CEAP class, and symptom/quality-of-life scores when requesting authorization for CAC or PEM.
Document rationale and reference trial evidence (e.g., VeClose for CAC; PEM systematic reviews/RCTs) to support medical necessity determinations.

Prior Authorization

Prior authorization required for investigational VenoValve — document investigational status

VenoValve is investigational; prior authorization should be obtained with documentation of investigational status, trial enrollment, or detailed medical rationale before coverage is considered.

Document that VenoValve is investigational and not FDA approved and include trial identifiers or enrollment status (e.g., SAVVE trial NCT04943172) when submitting authorization requests.
Provide detailed medical necessity justification and informed consent discussing investigational risks and limited human data.

Prior Authorization

Authorization must include duplex results and CEAP documentation

Authorization for ablation should be supported by duplex ultrasound demonstrating axial or pathologic reflux and documentation of CEAP clinical classification.

Submit a standing or reverse Trendelenburg duplex study documenting reflux duration ≥500 ms for the involved vein(s) and measured vein diameters (GSV/SSV/accessory ≥3 mm; perforator ≥3.5 mm where applicable).
Record CEAP clinical class and clinical findings (ulceration, bleeding, thrombophlebitis, venous stasis dermatitis, or pain) to show functional or physical impairment.

Prior Authorization

Prior authorization required — cyanoacrylate embolization is designated unproven/NMN for venous reflux

Prior authorization is required per policy for covered surgical and endovenous treatments; cyanoacrylate-based endovascular embolization for venous reflux is designated unproven/not medically necessary and may be denied.

Requests for cyanoacrylate-based embolization for venous reflux should include strong supporting evidence; absent convincing documentation, the request may be denied as unproven.
Prior authorization is required to distinguish covered reconstructive procedures from those designated unproven or excluded.

Prior Authorization

Reference InterQual CP for phlebectomy prior authorization determinations

When authorizing ambulatory phlebectomy procedures, reviewers should reference the updated InterQual CP: Procedures, Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein for clinical coverage details.

Use the InterQual phlebectomy criteria to determine medical necessity for phlebectomy procedures and to document required clinical indications.
Remove reliance on the prior Ambulatory Phlebectomy InterQual CP references as noted in the policy updates.

Billing Rule

Sclerotherapy coding and authorization guidance — use CPT 36465/36466 for non‑compounded foam per AMA

Coding for sclerotherapy was updated: for targeted extremity truncal non-compounded foam injections with ultrasound-guided compression maneuvers, use CPT 36465 or 36466 per AMA guidance when submitting authorizations and claims.

CPT 36468 (sclerosant for spider veins/telangiectasias) is considered cosmetic and excluded—do not authorize for reconstructive indications.
CPT 36470 and 36471 are covered for non-truncal, non-telangiectasia sclerotherapy up to three sessions per leg within a rolling 12‑month period; document session counts in authorization requests.

Prior Authorization

Operational limit: sclerotherapy up to three sessions per leg per rolling 12 months

Sclerotherapy with CPT 36470/36471 is operationally limited to up to three sessions per leg in a rolling 12‑month period; more than three sessions per leg within a year is considered cosmetic and excluded.

Define a session as a single date of service when CPT 36470 or 36471 is performed, and track sessions over the prior 365 days when processing authorizations or claims.
Authorization requests exceeding three sessions per leg in the prior 12 months should be denied as cosmetic according to the policy.

Note

Preferred treatment sequence: EVTA first-line; justify non‑thermal options

Guidelines and policy language indicate EVTA (endovenous thermal ablation) is the recommended first-line treatment for GSV/SSV incompetence; non-thermal options (UGFS, CAC, MOCA) may be considered in select situations and should be justified in the authorization.

When selecting non-thermal modalities, document why EVTA is unsuitable or contraindicated and include supporting anatomy and clinical rationale in the authorization request.
Reference guideline recommendations favoring EVTA for long-term outcomes when justifying selection of alternate modalities.

Documentation Required

Provide recent standing/reverse Trendelenburg duplex documenting diameter and reflux (≥500 ms)

Authorization must include a recent duplex ultrasound in the standing or reverse Trendelenburg position documenting vein diameter and reflux duration for the involved vein(s) (≥500 ms), as specified in policy criteria.

For truncal veins (GSV/SSV/Accessory) document diameter ≥3 mm and reflux duration ≥500 ms on a standing or reverse Trendelenburg duplex study.
For perforator veins, document diameter ≥3.5 mm and reflux duration ≥500 ms where applicable, and include the duplex report with the authorization.

Documentation Required

Authorization requires duplex confirmation of perforator reflux (>500 ms), diameter (≥3.5 mm), and CEAP class

For perforator vein interventions, authorization must include duplex ultrasound showing pathologic perforator reflux (>500 ms) and perforator diameter (≥3.5 mm), plus CEAP class documentation to support treatment.

Document that the perforator lies beneath a healed or active venous stasis ulcer when ablation is being requested for ulcer-directed therapy.
Include CEAP clinical class and supporting clinical impairment evidence in the authorization submission.

Denial Risk

Denial risk: perforator ablation with foam or adhesive considered unproven/NMN

Requests for perforator ablation using endovenous foam sclerotherapy or cyanoacrylate adhesive should be flagged for potential denial because the policy designates these techniques as unproven and not medically necessary for perforator veins.

If proposing foam or adhesive for isolated perforator treatment, include robust supporting evidence; absent convincing data, expect denial as unproven/NMN.
Alternative accepted approaches (RFA or EVLA) should be documented if available.

Denial Risk

Cosmetic exclusions — spider veins/telangiectasias excluded (CPT 36468)

Cosmetic procedures such as treatment of spider veins/telangiectasias are excluded; authorization requests for CPT 36468 or for indications limited to cosmetic appearance should be denied.

CPT 36468 is explicitly classified as cosmetic and does not improve a functional, physical, or physiological impairment.
Document functional impairment when requesting coverage for sclerotherapy codes that might otherwise be considered cosmetic.

Denial Risk

Denial risk if required duplex evidence (reflux/diameter) is absent

Absence of duplex ultrasound demonstrating required reflux duration and diameter thresholds undermines medical necessity; incomplete or missing duplex documentation may result in denial.

Standard thresholds include reflux duration ≥500 ms and applicable vein diameter criteria (GSV/SSV/accessory ≥3 mm; perforator ≥3.5 mm).
Submit complete duplex reports performed standing or in reverse Trendelenburg to avoid undermining the request.

Denial Risk

Denial risk for cyanoacrylate or foam on perforator/unsupported indications

Requests for cyanoacrylate embolization or foam sclerotherapy for perforator veins or other non-supported indications may be denied as unproven and not medically necessary.

Policy explicitly states endovascular embolization with cyanoacrylate for venous reflux and ablation of perforator veins with foam/adhesive are unproven/NMN.
Provide high-quality supporting evidence if proposing these procedures; otherwise, expect denial.

Billing Rule

Removed CPT codes — claims using removed codes (37500, 37799) may be denied

Claims submitted with CPT codes that were removed from the policy's applicable codes list (e.g., 37500 or 37799) may be denied; billing teams should not use removed codes.

The policy history notes removal of CPT 37500 and 37799 from the applicable codes list; do not bill with removed codes.
Use the current Applicable Codes table to select appropriate CPT codes for claims and authorizations.

Documentation Required

Document perforator vein etiology — exclude perforator incompetence secondary to acute DVT

When treating perforator veins, document the etiology—perforator incompetence secondary to acute deep vein thrombosis is excluded and may lead to denial if not explicitly ruled out.

Include clinical history and duplex findings that confirm perforator incompetence is not due to recent acute DVT.
If perforator incompetence is secondary to acute DVT, do not request authorization under the policy's permissive perforator criteria.

Billing Rule

Sclerotherapy coding: use CPT 36465/36466 for non‑compounded foam truncal injections per AMA

For non‑compounded foam sclerotherapy of truncal extremity veins, select CPT 36465 or 36466 per AMA guidance when submitting authorization or billing for ultrasound‑guided foam injections.

CPT 36465 = single incompetent extremity truncal vein; CPT 36466 = multiple incompetent truncal veins, same leg.
Ensure documentation describes the use of non‑compounded foam and ultrasound‑guided compression maneuvers to support coding selection.

Noninvasive imaging combining B‑mode and Doppler to assess venous flow and valve function; performed upright (standing or reverse Trendelenburg) for reflux measurement.

Positioning requirementPolicy requires duplex study performed in the standing or reverse Trendelenburg position for reflux assessment.

Cyanoacrylate adhesive embolization — definition

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

UGFS — ultrasound‑guided foam sclerotherapy definition

Ultrasound‑guided foam sclerotherapy (UGFS/PEM)Injection of polidocanol 1% microfoam (e.g., Varithena/PEM) under ultrasound guidance to damage endothelium and occlude varicose veins.

MOCA — mechanochemical ablation definition

Mechanochemical ablation (MOCA)Device‑based technique (e.g., ClariVein) combining mechanical endothelial injury with infusion of a sclerosing agent to induce vein occlusion.

Technique characteristicNon‑thermal, typically non‑tumescent; combines mechanical disruption with chemical sclerosant.

CAC/CAE — cyanoacrylate closure definition

CAC/CAE (cyanoacrylate closure)Endovenous embolization using cyanoacrylate‑based adhesive (e.g., VenaSeal) to occlude incompetent truncal veins; does not require tumescent anesthesia.

MOCA definition (additional)

MOCA — non‑thermal, non‑tumescent techniqueMechanochemical ablation is a non‑thermal, non‑tumescent technique using mechanical disruption plus infusion of sclerosant (e.g., ClariVein).

Reflux — minimum reversed flow duration >500 ms definition

Reflux (policy threshold)Minimum reversed flow duration >500 milliseconds (ms) on duplex ultrasound in superficial truncal veins (GSV, SSV, AAGSV, PAGSV) and specified perforating/deep veins.

Pathologic perforating vein — definition

Pathologic perforating vein (policy definition)A perforator with outward flow duration >= 500 ms on duplex and diameter >= 3.5 mm (in CEAP C2 context).

Superficial Vein — new/revised definition added in policy

Superficial Vein (policy addition)Definition added/clarified in policy: veins located above the muscular fascia (Superficial Vein).

Telangiectasias/Spider Veins — new/revised definition added in policy

Telangiectasias/Spider Veins (policy addition)Defined as dilated small superficial veins measuring less than 1 mm in diameter, predominantly in the lower extremities.

Tributary Vein — definition added/clarified

Tributary Vein (policy addition)Small superficial veins in the legs running close to the skin within the superficial plane of the subcutaneous layer (tributary veins).

Stab Phlebectomy — definition added in policy history

Stab Phlebectomy (definition added)Stab phlebectomy was added as a defined term in the policy (procedure for removal of superficial varicose tributaries via small stab incisions).

Removed definitions — list of definitions removed from the policy

Definitions removed in policy updateRemoved definitions include: Cosmetic Procedures; Reconstructive Procedures; Reticular Vein; Spider Vein; Superficial Thrombophlebitis.

Prior Authorization

Prior authorization — follow documented medical necessity and policy coding/documentation rules

No additional explicit prior authorization requirements are provided in these policy segments beyond the standard need to document medical necessity and follow the policy's diagnostic and coding requirements.

Continue to follow the policy's stated documentation (duplex, CEAP class, clinical impairment) and coding guidance when submitting authorizations.
Consult state/contractual rules and InterQual criteria where referenced for procedure‑specific requirements.

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

non_covered_added

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.

criteria_added

Required that incompetent perforator veins are not secondary to acute deep vein thrombosis and specified duplex ultrasound standing/reverse Trendelenburg requirement with reflux >= 500 ms for perforator veins.

language_clarified

Replaced requirement for 'Duplex Ultrasonography report' with 'duplex ultrasound study performed in the standing or reverse Trendelenburg position' to clarify ultrasound positioning for reflux measurement.

reflux_threshold_clarified

Clarified reflux threshold language to 'duration of reflux that is greater than or equal to 500 milliseconds (ms)' for GSV, SSV, accessory veins and perforating veins.

interqual_reference_update

Added reference to InterQual CP: Procedures, Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein and removed prior Ambulatory Phlebectomy references for specific procedure names.

definitions_added

Added multiple definitions including 'Superficial Vein', 'Telangiectasias/Spider Veins', 'Tributary Vein', and definitions for phlebectomy-related terms (stab, mini, etc.).

definitions_added

Added additional definitions for Superficial Vein, Telangiectasias/Spider Veins, Tributary Vein, and Stab Phlebectomy in subsequent history entries.

definitions_added

Added definitions for Superficial Vein, Stab Phlebectomy, Stab Avulsion, and Mini Phlebectomy across policy history entries.

definitions_removed

Removed definitions for Cosmetic Procedures, Reconstructive Procedures, Reticular Vein, Spider Vein, and Superficial Thrombophlebitis.

coding_and_coverage_changes

Updated coding guidance: removed CPT codes 37500 and 37799 from applicable codes; added instruction to refer to CPT 36465 or 36466 per AMA guidance for targeted extremity truncal foam sclerosant injections; revised which sclerosclerosis CPTs are considered cosmetic or covered (36468 cosmetic; 36470/36471 covered up to three sessions per leg per year).

Summary of material revisions: the policy was broadened to explicitly include endovenous foam sclerotherapy (PEM) and cyanoacrylate-based adhesive among accepted treatment modalities for GSV, SSV, and accessory veins when all medical necessity criteria are met, and duplex ultrasound language was clarified to require studies performed in the standing or reverse Trendelenburg position documenting reflux ≥ 500 ms. In parallel, the policy added explicit not medically necessary (NMN) designations for endovascular embolization with cyanoacrylate for venous reflux and for ablation of incompetent perforator veins using foam or cyanoacrylate because of insufficient evidence. New requirements clarify that incompetent perforator veins must not be secondary to acute deep vein thrombosis and that perforator diameter and reflux thresholds apply for consideration. Coding and sclerotherapy guidance was updated (e.g., CPT 36465/36466 guidance; CPT 36468 remains cosmetic; CPTs 36470/36471 limited to three sessions per leg/year), and references to InterQual phlebectomy criteria were added for ambulatory phlebectomy determinations.