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 invasive procedures for the treatment of varicose veins are considered medically reasonable 
and necessary when ALL of the following criteria have been met: 
 
1. An evaluation of the patient has been performed including a history and physical examination, the Clinical 
(C), Etiological (E), Anatomical (A), and Pathophysiological (P) (CEAP) clinical classification and the revised 
Venous Clinical Severity Score (VCSS), and 
2. A duplex scan of the deep and superficial venous systems supports the examination findings, and 
3. 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 
4. The documentation supports signs and/or symptoms that interfere with activities of daily living and/or 
quality of life, and 
5. The CEAP clinical classification is C1 to C6 with the following criteria: 
 
a. 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. 
b. 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. 
c. For patients who meet any one of the following criteria, the mandatory conservative therapy prior to the 
invasive procedure may be waived. 
 
-VCSS 6 or more 
-C4-C6 disease (skin changes assigned to venous disease, healed venous leg ulceration, and active venous leg 
ulceration) 
-Hemorrhage 
-Recurrent superficial thrombophlebitis 
 
You can find this rule in the Local Coverage Determination (LCD) - Treatment of Chronic Venous 
Insufficiency of the Lower Extremities (L34924) - Effective December 27, 2020.  
The rules say that  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. 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 rule in the 
Local Coverage Determination (LCD) - Treatment of Chronic Venous Insufficiency of the Lower Extremities 
(L34924) - Effective December 27, 2020. 
 
The rules say that 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. You can find this rule in the Local Coverage Determination (LCD) - 
Treatment of Chronic Venous Insufficiency of the Lower Extremities (L34924) - Effective December 27, 2020. 
 
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.