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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 Terminology of veins discussed within this LCD
Superficial, deep and perforating veins make up the lower extremity venous system. Superficial veins, which
are located between the deep fascia and the skin, include the telangiectasia veins, the reticular veins and the
main axial (truncal) superficial veins; the great and small saphenous veins and their tributaries.2,7 Deep veins,
which lie beneath the muscular fascia, include the following: inferior vena cava, common iliac, internal iliac,
external iliac, pelvic, gonadal, broad ligament, common femoral, deep femoral, femoral, popliteal, crural
(anterior tibial, posterior tibial, or peroneal), and muscular (gastrocnemius, soleus and other).3,7,8 Perforating
veins, which penetrate the muscular fascia and connect the superficial and deep veins, include numerous veins
from those of the foot, the medial and lateral calf, and the thigh.7
Telangiectasia veins (also known as "spider veins") are small, dilated, flat, thin-walled, blue or red veins <1
mm in diameter that are seen near the surface of the skin.2 Reticular veins are a network of veins parallel to the
skin surface and lying between the saphenous fascia and dermis, which drain the lower extremity skin and
subcutaneous tissue and have a diameter 1-3 mm (also known as blue veins or feeder veins).2
The axial superficial veins communicate with the deep venous system at different locations. The point where
the great saphenous vein (GSV) joins the common femoral vein, the saphenofemoral junction (SFJ), is located
proximally at the groin. The point where the small saphenous vein (SSV) joins the popliteal vein, the
saphenopopliteal junction (SPJ), is typically located behind the knee. Clinically significant reflux can also be
found in accessory great saphenous veins (i.e., Anterior Accessory Great Saphenous Vein [AAGSV] or
Posterior Accessory Great Saphenous Vein [PAGSV]) which parallel the GSV in the saphenous compartment,
the SSV, or perforating veins. The perforator veins drain from the superficial veins toward the deep
(intramuscular) veins. Pathologic perforator veins are defined by outward flow duration >500 ms, vein
diameter >3.5 mm and located underneath skin damage or ulceration.7 Variations in the anatomy of the deep
and superficial venous systems are common.
The American College of Phlebology Guidelines Committee10 updated their evidence-based recommendations
for treatment of superficial venous disease of the lower leg. They recommend that named veins (great
saphenous vein [GSV], small saphenous vein [SSV], anterior accessory of the great saphenous vein [AAGSV],
posterior accessory of the great saphenous vein [PAGSV], intersaphenous vein [Vein of Giacomini]) must have
a reflux time greater than 500 milliseconds regardless of the reported vein diameter. Treatment indications
include pain or other discomfort (i.e. heaviness, fatigue, soreness, or burning), edema, recurrent superficial
phlebitis, stasis dermatitis or ulceration. The committee defines medically necessary as a CEAP classification
of C2 or higher. Endovenous thermal ablation (laser and radiofrequency) and chemical/cyanoacrylate adhesive
is the preferred treatment for saphenous and accessory saphenous (GSV, SSV, AAGSV, PAGSV) vein
incompetence. MOCA may also be used to treat truncal venous reflux. The committee recommends that open
surgery is appropriate in veins not amenable to endovenous procedures but otherwise is not recommended
because of increased pain, convalescent time, and morbidity.
Covered Indications
1.Invasive procedures will be considered medically reasonable and necessary if the patient meets the criteria
as outlined in this LCD, and the intervention is addressed and supported in the plan of care, for a 90 day
episode of care, that includes a specific treatment plan determined by the assessment and evaluation of the
lower extremity venous incompetence.
2. Invasive procedures for the treatment of varicose veins are considered medically reasonable and necessary
when ALL of the following criteria have been met:
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
A duplex scan of the deep and superficial venous systems supports the examination findings,3 AND
A duplex scan confirms the presence of reversed venous flow (reflux) with provocative maneuvers in the
saphenous, or perforator veins is 500 milliseconds or greater3 and absence of deep venous obstruction, AND
The documentation supports signs and/or symptoms that interfere with activities of daily living and/or
quality of life, AND
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 <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 one of the following criteria, the mandatory conservative therapy prior to the
invasive procedure may be waived.
VCSS =6
C4-C6 disease (skin changes assigned to venous disease, healed venous leg ulceration, and active
venous leg ulceration)
Hemorrhage
Recurrent superficial thrombophlebitis
3. Incompetent perforator vein (IPV) management by foam sclerotherapy or thermal ablation, will be
considered medically reasonable and necessary when:
An active venous ulcer is in close proximity to the IPV, OR
The proximal significant reflux has been treated and an IPV persists under or adjacent to a healed venous
ulcer, OR
The proximal and regional venous reflux has been treated and there is persisting focal pain and tenderness or
stasis dermatitis overlying an IPV, OR
The incompetent perforator demonstrates reflux >500 ms and diameter > 3.5 mm.
4. Ultrasound guided foam sclerotherapy (UGFS), physician-compounded foam (PCF) and non-compounded
foam (NCF) will be considered medically reasonable and necessary for ablation of incompetent saphenous
veins and tributary veins for the treatment of patients with symptomatic CEAP clinical classification C2 to C6
disease. UGFS is also considered medically reasonable and necessary for ablation of venous malformations.
5. Liquid sclerotherapy will be considered medically reasonable and necessary for ablation of incompetent
saphenous veins and tributary veins for the treatment of patients with symptomatic CEAP clinical classification
C2 to C6 disease. Liquid sclerotherapy is also considered medically reasonable and necessary for the treatment
of patients with symptomatic CEAP clinical classification C1 (telangiectasia and their feeding reticular veins)
with spontaneous and/or traumatic venous hemorrhage.
6. 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.
7. Chemical adhesives 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.
8. Mechanochemical ablation (MOCA) 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.
9. It is the responsibility of the provider to comply with all applicable State and Federal laws related to the
human use of agents.
10. Surgery will be considered medically reasonable and necessary for treatment of incompetent saphenous
veins for patients with symptomatic CEAP clinical classification C2 to C6 disease.
11. Phlebectomy will be considered medically reasonable and necessary for symptomatic bulbous varicosities
greater than 3mm diameter above and below the knees. If saphenous vein ablation is performed, phlebectomy
may be staged or concomitant depending upon the vein pattern and/or provider preferences.
Limitations
The following are considered not medically reasonable and necessary:
1. The treatment of CEAP clinical classification C0 (no visible or palpable signs of venous disease) is
considered cosmetic, and therefore, not reasonable and necessary for the purposes of Medicare coverage.
2. The treatment of CEAP clinical classification C1 (telangiectasias or reticular veins) will be considered
cosmetic, and therefore, not reasonable and necessary for the purposes of Medicare coverage except in patients
with spontaneous and/or traumatic venous hemorrhage.
You can find this information in Medicare's FUTURE Local Coverage Determination (LCD): Treatment of
Chronic Venous Insufficiency of the Lower Extremities (L34924).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.