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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:
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:
&#8722; 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
&#8722; A duplex scan of the deep and superficial venous systems supports the examination
findings,3 AND
&#8722; 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
&#8722; The documentation supports signs and/or symptoms that interfere with activities of daily living
and/or quality of life, AND
&#8722; The CEAP clinical classification is C1 to C6 with the following criteria:
&#9642; 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.
&#9642; 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.
&#9642; For patients who meet any one of the following criteria, the mandatory conservative
therapy prior to the invasive procedure may be waived.
&#9642; VCSS greater than or equal to 6
&#9642; C4-C6 disease (skin changes assigned to venous disease, healed venous leg
ulceration, and active venous leg ulceration)
&#9642; Hemorrhage
Recurrent superficial thrombophlebitis
3. Incompetent perforator vein (IPV) management by foam sclerotherapy or thermal ablation, will be
considered medically reasonable and necessary when:
&#8722; An active venous ulcer is in close proximity to the IPV, OR
&#8722; The proximal significant reflux has been treated and an IPV persists under or adjacent to a
healed venous ulcer, OR
&#8722; The proximal and regional venous reflux has been treated and there is persisting focal pain and
tenderness or stasis dermatitis overlying an IPV, OR
&#8722; The incompetent perforator demonstrates reflux greater than 500 ms and diameter greater than
3.5 mm.
4. Ultrasound guided foam sclerotherapy (UGFS), physician-compounded foam (PCF) and noncompounded
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.
You can find this rule in the Local Coverage Determination for Treatment of Chronic Venous Insufficiency of
the Lower Extremities, L34924 (eff 12/27/20).
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