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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 varicose veins are caused by venous insufficiency as a result of valve reflux (incompetence). The venous insufficiency results in dilated, tortuous, superficial vessels that protrude from the skin of the lower extremities. Spider veins (telangiectases) are dilated capillary veins that are most often treated for cosmetic purposes. The accepted treatments for eliminating saphenous (great saphenous vein (GSV), anterior accessory GSV (AAGSV), small saphenous vein (SSV)) reflux (saphenofemoral or saphenopopliteal) are radiofrequency ablation (RFA), laser ablation (EVLA), polidocanol microfoam (PEM), cyanoacrylate embolization (CAE) ablation, and mechanochemical ablation (MOCA). Coverage is only for devices with FDA approval or clearance consistent with saphenous ablation and used according to its approved instructions for use (IFU). RFA and EVLA are classified as thermal tumescent (TT) techniques; PEM, CAE and MOCA are non-thermal non-tumescent (NTNT) techniques. Each endovenous ablation approach has advantages and disadvantages; which one is best depends on the unique clinical/anatomical scenario. While saphenous vein ligation and stripping remains an important option in selected cases, it has been largely supplanted by endovenous ablation therapy as primary treatment of saphenous (axial/truncal) vein incompetence. The treatments to eliminate the saphenous vein reflux will be considered medically necessary if the patient remains symptomatic after a six-week trial of conservative therapy and has reflux in a saphenous vein. The treatments for symptomatic varicose tributaries are either compressive sclerotherapy or microphlebectomy. The treatments of the tributary veins will be considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative therapy. The components of the conservative therapy include, but are not limited to:
- weight reduction,
- a daily exercise plan,
- periodic leg elevation, and
- the use of graduated compression stockings.
The conservative therapy must be documented in the medical record. Inability to tolerate compressive bandages or stockings and the reason for such intolerance must be documented in the medical record. The patient is considered symptomatic if any of the following signs and symptoms of significantly diseased vessels of the lower extremities are documented in the medical record:
- stasis ulcer of the lower leg,
- significant pain and significant edema that interferes with activities of daily living,
- bleeding associated with the diseased vessels of the lower extremities,
- recurrent episodes of superficial phlebitis,
- stasis dermatitis, or
- refractory dependent edema.
Coverage of endovenous ablation therapy is limited to patients with:
- a maximum vein diameter of 12 mm for CAE, PEM and MOCA; and
- absence of thrombosis or vein tortuosity, which would impair catheter advancement (except for PEM).
Medicare includes payment for the ultrasound guidance in the payment for endovenous ablation procedures.
You can find this rule in the Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD): Varicose Veins of the Lower Extremity, Treat of (L33575).
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.