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 state that a duplex ultrasound examination is considered medically necessary and will be allowed 
when performed within 1 week (preferably within 72 hours) of EFRA to check for any evidence of thrombus 
extension from the saphenofemoral junction into the deep system. 
A. Indications for surgical treatment and 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, aching, cramping, burning, itching and/or swelling during activity or after 
prolonged standing 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 
3. The treatment of spider veins/telangiectasis will be considered medically necessary only if there 
is associated hemorrhage. 
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 20 mm for ERFA or 30 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. 
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 also considered 
cosmetic, and therefore not covered unless there is associated bleeding. 
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. 
7. Post procedure Doppler ultrasound studies will be allowed if medically necessary. 
The 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. 
If sclerotherapy is used with endovenous ablation, it may be covered if the criteria for reasonable and necessary 
as described in this LCD are met. 
The treatment of asymptomatic veins with endoluminal ablation or sclerotherapy is not considered 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. 
You can find this rule in the Local Coverage Determination (LCD) for Treatment of Varicose Veins of the 
Lower Extremities, L34536. 
 
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.