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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 CFR 422.101.
The rules say that treatment for Symptomatic Chronic Venous Insufficiency or Varicose Veins (VV), in the
absence of bleeding, phlebitis or skin necrosis, may be covered as medically necessary with:
1. A documented 3-month trial of conservative therapy including graduated compression stockings with a
minimum of (12-18 mmHg), weight reduction to BMI less than 35, therapeutic leg elevation, and an
exercise program of calf muscle pumping activity with compression of the involved veins, which results
in limited alteration/improvement of symptoms or findings without satisfactory endpoint, and
2. Duplex venous studies of the involved lower extremity(s), mapping size and course of the greater and
lesser saphenous vein and prominent tributaries and demonstrating the:
o Presence and Patency of the Deep Venous System.
o Absence of Deep Venous Thrombosis, and
o Documented Incompetence (reflux greater than 500msec) of the Valves of the Saphenous,
Perforator or Deep venous systems consistent with the patient's symptoms and findings.
Services will be considered reasonable and necessary only if performed by appropriately trained personnel.
Endovenous Radiofrequency and Laser Ablation Occlusion Therapy (ERFA) (EVLT) are minimally invasive
alternatives to ligation and stripping. Multiple System devices are FDA approved for endovascular coagulation
and closure of large veins in the lower extremities including the saphenous veins at the saphenofemoral and
saphenopopliteal junctional regions. It is the responsibility of the treating physician to determine and insure
FDA approval of the device employed for the specific vein obliteration planned. To be considered for coverage
of these procedures, all of the following criteria must be met:
1. Patient's anatomy is amenable to laser or radiofrequency catheter with the absence of tortuosity that
would impair catheter passage and distance separation from skin as to preclude thermal injury. Unless
documented by the supplier of the RFA or LA device, maximal vein diameter may not exceed 20mm as
there is insufficient data to suggest devices presently marketed for this purpose are effective for
occlusion of veins above this diameter.
2. Non-Aneurysmal Saphenous vein or portion of vein at risk of rupture, hemorrhage or adjacent skin
injury. Large veins adjacent to aneurysm formation (fusion of skin and vein wall) are optimal
candidates for ERFA or EVLT in that adjacent aneurysm and preclude further need for treatment.
3. Maximal vein diameter is clinically appropriate for catheter or sheath employed.
4. No planned treatment of incompetent valves or risk of direct injury to perforator veins of the calf that
may induce thrombus propagation into the deep vein system.
5. Absence of clinically significant or symptomatic peripheral arterial disease.
You can find this rule at Local Coverage Determination (LCD): Treatment of Varicose Veins and Venous
Stasis Disease of the Lower Extremities (L34924) (eff. 11/14/19).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.