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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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
The rules say that Medicare will consider invasive procedures (only with the techniques outlined in this local 
coverage determination (LCD) and under the conditions described) as reasonable and necessary when 
documentation in the medical record includes a history, physical examination, CEAP clinical classification, and 
a venous duplex scan documenting reflux (>500 msec). 
1. Liquid sclerotherapy will be considered reasonable and necessary to treat telangiectasias, reticular 
veins, small varicose veins (3-6 mm), residual or recurrent veins following endovenous ablation or 
surgery, and perforator veins. Treatment of telangiectasias and reticular veins (C1) (<3 mm) is 
considered reasonable and necessary with documentation of spontaneous and/or traumatic venous 
hemorrhage, OR for dilated intradermal veins in the elderly judged to be a substantial risk for 
hemorrhage with minimal trauma, OR near an active or healed ulcer if judged to contribute to local 
venous hypertension. 
2. Saphenous veins (GSV, SSV, AAGSV) management, with UGFS, endovenous thermal ablation 
(radiofrequency or laser), chemical adhesive (cyanoacrylate embolization), MOCA, and surgery 
(surgical ligation and stripping) is considered reasonable and necessary with documentation in the 
medical record of CEAP class C2-C6 disease, reflux (>500 msec), and ANY of the following signs or 
symptoms:  
a. ulceration secondary to venous stasis 
b. significant pain or significant edema associated with saphenous reflux that interferes with 
activities of daily living (ADLs) 
c. bleeding associated with ruptured superficial varicosity 
d. recurrent episodes of superficial phlebitis 
e. stasis dermatitis 
f. refractory dependent edema 3. Incompetent perforator veins (IPVs) are the most common cause of recurrent varicose veins after 
treatment. Minimally invasive treatments have replaced traditional surgical treatments for IPVs. UGFS 
and endovenous thermal ablation with either radiofrequency or laser energy sources will be considered 
reasonable and necessary with the following conditions:  
a. Demonstrated perforator reflux >500 msec; AND 
b. No saphenous reflux (greater, small, or accessory) and/or symptomatic varicose tributaries; 
AND 
c. An active venous ulcer; AND 
d. The IPV is at least 3.5 mm in diameter; AND 
e. The perforator is in the vicinity of the ulcer. 
You can find this rule in Local Coverage Determination (LCD) Treatment of Varicose Veins of the Lower 
Extremities L39121. 
 
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.