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 varicose veins are caused by venous insufficiency as a result of valve reflux (incompetence). 
The venous insufficiency results in dilated, tortuous, superficial vessels that protrude from the skin of the lower 
extremities. Spider veins (telangiectases) are dilated capillary veins that are most often treated for cosmetic 
purposes. 
 
Varicose veins are caused by venous insufficiency as a result of valve reflux (incompetence). The venous 
insufficiency results in dilated, tortuous, superficial vessels that protrude from the skin of the lower extremities. 
Spider veins (telangiectases) are dilated capillary veins that are most often treated for cosmetic purposes.  
 
The treatments for symptomatic varicose tributaries are either compressive sclerotherapy or microphlebectomy. 
The treatments of the tributary veins will be considered medically necessary if saphenous reflux is not present 
or already successfully eliminated, the veins are > than 4 mm in diameter and if the patient remains 
symptomatic after a six-week trial of conservative therapy.   
The components of the conservative therapy include but are not limited to: 
 
    weight reduction, 
    a daily exercise plan, 
    periodic leg elevation, and 
    the use of graduated compression stockings. 
 
The conservative therapy must be documented in the medical record. Inability to tolerate compressive bandages 
or stockings and the reason for such intolerance must be documented in the medical record. 
 
The patient is considered symptomatic if any of the following signs and symptoms of significantly diseased 
vessels of the lower extremities are documented in the medical record: 
 
    stasis ulcer of the lower leg, 
    significant pain and significant edema that interferes with activities of daily living, 
    bleeding associated with the diseased vessels of the lower extremities, 
    recurrent episodes of superficial phlebitis, 
    stasis dermatitis, or 
    refractory dependent edema. 
 Coverage of endovenous ablation therapy is limited to patients with:  
 
    a maximum vein diameter of 12 mm for CAE, PEM and MOCA; and 
    absence of thrombosis or vein tortuosity, which would impair catheter advancement (except for PEM). 
 
Coil embolization is non-covered for any varicose vein procedure. 
The following interventional treatments are not considered medically reasonable or necessary and are denied as 
such: 
 
    Surgery, endovenous ablation, or sclerotherapy are typically not performed for varicose veins that develop or 
worsen during pregnancy because most will spontaneously resolve or improve after delivery. 
    Reinjection following recanalization or failure of vein closure without recurrent signs or symptoms. 
    Sclerotherapy of the saphenous vein at its junction with the deep system. 
    Noncompressive sclerotherapy. 
    Compressive sclerotherapy for large, extensive or truncal varicosities. 
    Sclerotherapy, ligation and/or stripping of varicose veins, or endovenous ablation therapy are generally not 
covered for patients with severe distal arterial occlusive disease; obliteration of deep venous system; an allergy 
to the sclerosant; or a hypercoaguable state. 
    Any interventional treatment that uses equipment or sclerosants not approved for such purposes by the FDA 
 
You can find this rule in the Local Coverage Determination (LCD) Varicose Veins of the Lower Extremity, 
Treatment of L33575. 
 
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.