Treatment of varicose veins may be performed for both medically necessary and cosmetic reasons. Therefore, the medical need for this type of procedure must be established by documenting that the enrollee has significant symptoms that cannot be adequately managed with more conservative, less invasive measures, such as leg elevation and compression therapy. When conservative treatment measures fail, other treatment for varicose veins may include sclerotherapy, stab phlebectomy, saphenous vein stripping, radiofrequency ablation, endovenous laser therapy, or subfascial endoscopic perforator surgery.
Treatment of telangiectasia or varicose veins less than three (3) mm in diameter by any method is not covered, as such treatment is considered cosmetic in nature. Sclerotherapy is not covered for the following conditions, as it is considered investigational, experimental or unproven:
· As a sole treatment of varicose tributaries without associated occlusion of the saphenofemoral or saphopopliteal junction
· The incompetence is isolated to the perforator veins
· Treatment of the saphenous vein at its junction
A. Sclerotherapy, stab phlebectomy, radiofrequency ablation, saphenous vein stripping and endovenous laser therapy for treatment of symptomatic saphenous varicose veins is covered when one of the following criteria is met:
1. There is documentation of any one of the following:
a. Leg ulcerations that are due to saphenous vein insufficiency and are refractory to conservative management
b. Recurrent bleeding from the saphenous vein, other varicosities, or telangiectasia
c. History of a single significant episode of bleeding, especially if a transfusion was required
2. There is documentation of all of the following:
a. Incompetence/reflux with Doppler evaluation and/or Duplex ultrasonography of the symptomatic varicosity, and documented vessel size greater than or equal to three (3) mm
b. The enrollee’s physician has documented failure of conservative management for three (3) consecutive months
c. At least one of the following associated clinical conditions:
· Pain in the affected extremity resulting in impaired mobility or inability to perform activities of daily living
· Recurrent phlebitis or thrombophlebitis
· Refractory dependent edema
· Persistent stasis dermatitis
3. Sclerotherapy for the treatment of varicose tributaries when performed in combination with saphenous vein stripping and stab phlebectomy, radiofrequency ablation and endovenous laser therapy.
B. Subfascial endoscopic perforator surgery is covered when all of the following criteria are met:
1. There is documented Doppler evaluation and/or Duplex ultrasonography of the incompetent perforator on the medial aspect of the calf being treated
2. There is documented failure of conservative management for three (3) months
3. There is documentation of at least one (1) of the following:
a. Venous stasis dermatitis/ulceration
b. Chronic venous insufficiency
