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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 state that Medicare will consider invasive procedures 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. 
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 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 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, 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:  
- Demonstrated perforator reflux greater than 500 msec; AND 
- No saphenous reflux (greater, small, or accessory) and/or symptomatic varicose 
tributaries; AND 
- An active venous ulcer; AND 
- The IPV is at least 3.5 mm in diameter; AND 
- The perforator is in the vicinity of the ulcer. Pre-operative venous studies are considered reasonable and necessary prior to varicose vein treatment when 
initially performed by an accredited vascular technician. The study will fully define the anatomy, size, and 
tortuosity of the great and lesser saphenous vein, superficial venous segments, and perforators and will 
determine the extent of venous valvular incompetence. Medicare will cover a pre-procedure duplex scan used 
in conjunction with other non-invasive physiologic testing to determine the extent and configuration of the 
varicosities. It is expected that these studies will be performed by the physician planning to provide the therapy 
or by a registered vascular technologist (RVT). Medicare will cover intraoperative ultrasonic guidance in 
situations when it is medically necessary. Also, Medicare includes payment for the ultrasound in the payment 
for ERFA and laser ablation procedures. Palmetto GBA will allow for post procedure studies within a 6-month 
period. 
Services that are not reasonable and necessary cannot be covered by Medicare in the following: 
1. CEAP clinical classification C0 (no visible or palpable signs of venous disease) is considered cosmetic, 
and therefore, not reasonable and necessary and cannot be covered by Medicare; 
2. CEAP clinical classification C1 (telangiectasias or reticular veins) is considered cosmetic and not 
reasonable and necessary with the exception of documentation of spontaneous and or traumatic venous 
hemorrhage; 
3. Severe distal arterial occlusive disease; 
4. Acute DVT or superficial vein thrombosis; 
5. Allergy to the sclerosant; 
6. Pregnancy; 
7. Advanced generalized systemic disease that limits quality-of-life (QOL) improvements would require a 
statement of the objective of treatment in such cases; 
8. Failure of a vein closure without recurrent signs or symptoms; 
9. Any interventional treatment that uses equipment not approved for such purposes by the FDA 
You can find this information in the 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.