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 for endovenous ablation therapy: Indications for surgical treatment: For example venous 
ligation, vein stripping and/or sclerotherapy: 1. A 3-month trial of conservative therapy such as exercise, 
periodic leg elevation, weight loss, compressive therapy, and avoidance of prolonged immobility where 
appropriate, has failed, AND 2. The patient is symptomatic and has one, or more, of the following: a. Pain or 
burning in the extremity severe enough to impair mobility b. Recurrent episodes of superficial phlebitis c. Non-
healing skin ulceration d. Bleeding from a varicosity e. Stasis dermatitis f. Refractory dependent edema.  
B. Indications for ERFA or laser ablation: In addition to the above (see A), the patient's anatomy and clinical 
condition are amenable to the proposed treatment including ALL of the following: 1. Absence of aneurysm in 
the target segment. 2. Maximum vein diameter of 12 mm for ERFA or 20 mm for laser ablation 
3. Absence of thrombosis or vein tortuosity, which would impair catheter advancement. ?4. The absence of 
significant peripheral arterial diseases. C. Limitations for ERFA and laser ablation: 1. ERFA and laser ablation 
are covered only for the treatment of symptomatic varicosities of the lesser or greater saphenous veins and their 
tributaries which have failed 3 months of conservative therapy. 2. Intra-operative ultrasound guidance is not 
separately payable with ERFA, laser ablation, and sclerotherapy. 3. The treatment of asymptomatic varicose 
veins, or symptomatic varicose veins without a 3-month trial of conservative measures, by any technique will 
be considered cosmetic and therefore not covered. 4. The treatment of spider veins or superficial telangiectasis 
by any technique is considered cosmetic, and therefore not covered. 5. Coverage is only for devices specifically 
FDA-approved for these procedures. 6. One pre-operative Doppler ultrasound study or duplex scan will be 
covered. Noridian notes that stab phlebectomy of the same vein performed on the same day as endovenous 
radiofrequency or laser ablation may be covered if the criteria for reasonable and necessary as described in this 
LCD are met. Noridian notes that if sclerotherapy is used with endovenous radiofrequency ablation, it may be 
covered if the criteria for reasonable and necessary as described in this LCD are met. Noridian will not consider 
the treatment of asymptomatic veins with endoluminal ablation or sclerotherapy medically reasonable and 
necessary. If it is determined on review that the varicose veins were asymptomatic, the claim will be denied as 
a noncovered (cosmetic) procedure. Compliance with the provisions in this policy is subject to monitoring by 
post payment data analysis and subsequent medical review. You can find this information in the Local 
Coverage Determination (LCD): Treatment of Varicose Veins of the Lower Extremities (L34209). 
 
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.