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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 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say Limitations: Duplex ultrasound is often used in conjunction with other non-invasive physiologic 
testing to define the anatomy and physiology of the varicose vein network prior to injection or surgical 
intervention. There is adequate evidence that the pre-procedural ultrasound is helpful, and Medicare will cover 
a pre procedure Duplex scan CPT code 93970 or 93971) used in conjunction with other non-invasive 
physiologic testing CPT code to determine the extent and configuration of the varicosities. CGS expects that 
these studies will be performed by the provider planning to provide the therapy. CGS will allow this study once 
per provider or provider group. Clinical experience supports the use of ultrasound during the sclerotherapy 
procedure, and evidence shows that the outcomes may be improved, and complication rates may be minimized 
when ultrasound guidance is used. 
 
Medicare will cover intraoperative ultrasonic guidance in situations when it is medically necessary. 
 
Medicare includes payment for the ultrasound in the payment for the ERFA and laser ablation procedures. 
 
Cosmetic surgery is statutorily excluded from coverage by Medicare. The following interventional treatments 
are considered to be cosmetic and will be denied as such: 
 
    Interventional treatment of asymptomatic varicosities. 
    Treatment of telangiectases (36468). 
    Sclerotherapy for cosmetic purposes. 
 
Medicare cannot cover services which are not reasonable and necessary for the treatment of illness or injury or 
to improve the functioning of a malformed body member. The following interventional treatments are not 
considered medically reasonable or necessary and are denied as such: 
     Interventional treatment of symptomatic varicosities without documentation of a failed six week trial of 
conservative therapy. 
    Sclerotherapy for vessels larger than 4 mm in diameter. 
    Reinjection following recanalization or failure of vein closure without recurrent signs or symptoms. 
    Sclerotherapy of the saphenous vein at its junction with the deep system. 
    Noncompressive sclerotherapy. 
    Compressive sclerotherapy for large, extensive or truncal varicosities. 
    Sclerotherapy, ligation and/or stripping of varicose veins, or endovenous ablation therapy are not covered for 
pregnant women, or patients with the inability to tolerate compressive bandages or stockings; severe distal 
arterial occlusive disease; obliteration of deep venous system; an allergy to the sclerosant; or a hypercoaguable 
state. 
    Any interventional treatment that uses equipment or sclerosants not approved for such purposes by the FDA. 
    Laser ablation of veins with a diameter greater than 20 mm. 
    Endovenous ablation therapy in the presence of thrombosis or venous tortuosity which would impair catheter 
advancement. 
 
CPT codes 37760 and 37761 should not be reported in conjunction with CPT codes 76937, 76942, 76998 or 
93971. You can find this information in Medicare's Local Coverage Determination (LCD): Varicose Veins of 
the Lower Extremity, Treatment of (L34082). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.