Appeal type: unknown
Decision: unknown

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 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that invasive procedures for the treatment of varicose veins are considered medically reasonable 
and necessary when ALL of the following criteria are met: 
 
1. An evaluation of the patient has been performed including a history and physical examination, the CEAP 
clinical classification and the revised Venous Clinical Severity Score (VCSS), AND 
2. A duplex scan of the deep and superficial venous systems supports the examination findings, AND 
3. A duplex scan confirms the presence of reversed venous flow (reflux) with provocative maneuvers in the 
saphenous, or perforator veins is 500 milliseconds or greater and absence of deep venous obstruction 
4. The documentation supports signs and/or symptoms that interfere with activities of daily living and/or 
quality of life 
5. The CEAP clinical classification is C1 to C6 with the following criteria 
 
-Treatment of C1 disease (telangiectasia and their feeding reticular veins) is considered medically reasonable 
and necessary for patients with spontaneous and/or traumatic venous hemorrhage. 
-For patients with C2 or C3 disease and VCSS less than 6, the plan of care shall include documentation of a 
period of conservative therapy (2 to 4 weeks) including graduated compression 20-30 mmHg or greater, 
ambulation, elevation, and avoiding prolonged sitting and standing. 
-For patients who meet any of the following criteria, the mandatory conservative therapy prior to the invasive 
procedure may be waived. 
 
a. VCSS of 6 or more 
b. C4-C6 disease (skin changes assigned to venous disease, healed venous leg ulceration, and active venous leg 
ulceration) 
c. Hemorrhage 
d. Recurrent superficial thrombophlebitis 
 
You can find this rule in the Local Coverage Determination (LCD) - Treatment of Chronic Venous 
Insufficiency of the Lower Extremities (L34924) - Effective December 27, 2020. 
 
The rules say that that thermal ablation (radiofrequency or laser) will be considered medically reasonable and 
necessary for ablation of incompetent saphenous veins for the treatment of patients with symptomatic CEAP 
clinical classification C2 to C6 disease. You can find this rule in the Local Coverage Determination (LCD)  he 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 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that invasive procedures for the treatment of varicose veins are considered medically reasonable 
and necessary when ALL of the following criteria are met: 
 
1. An evaluation of the patient has been performed including a history and physical examination, the CEAP 
clinical classification and the revised Venous Clinical Severity Score (VCSS), AND 
2. A duplex scan of the deep and superficial venous systems supports the examination findings, AND 
3. A duplex scan confirms the presence of reversed venous flow (reflux) with provocative maneuvers in the 
saphenous, or perforator veins is 500 milliseconds or greater and absence of deep venous obstruction 
4. The documentation supports signs and/or symptoms that interfere with activities of daily living and/or 
quality of life 
5. The CEAP clinical classification is C1 to C6 with the following criteria 
 
-Treatment of C1 disease (telangiectasia and their feeding reticular veins) is considered medically reasonable 
and necessary for patients with spontaneous and/or traumatic venous hemorrhage. 
-For patients with C2 or C3 disease and VCSS less than 6, the plan of care shall include documentation of a 
period of conservative therapy (2 to 4 weeks) including graduated compression 20-30 mmHg or greater, 
ambulation, elevation, and avoiding prolonged sitting and standing. 
-For patients who meet any of the following criteria, the mandatory conservative therapy prior to the invasive 
procedure may be waived. 
 
a. VCSS of 6 or more 
b. C4-C6 disease (skin changes assigned to venous disease, healed venous leg ulceration, and active venous leg 
ulceration) 
c. Hemorrhage 
d. Recurrent superficial thrombophlebitis 
 
You can find this rule in the Local Coverage Determination (LCD) - Treatment of Chronic Venous 
Insufficiency of the Lower Extremities (L34924) - Effective December 27, 2020. 
 
The rules say that that thermal ablation (radiofrequency or laser) will be considered medically reasonable and 
necessary for ablation of incompetent saphenous veins for the treatment of patients with symptomatic CEAP 
clinical classification C2 to C6 disease. You can find this rule in the Local Coverage Determination (LCD) - Treatment of Chronic Venous Insufficiency of the Lower Extremities (L34924) - Effective December 27, 
2020. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.