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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 saphenous vein ligation and division is the detachment of the saphenous vein (GSV, SSV, 
AGSV) through an incision at the groin at its confluence with the saphenofemoral junction and common 
femoral vein. It is the traditional treatment and is called high ligation and saphenous vein stripping. The 
primary goal is removal of the refluxing veins at the saphenofemoral junction. Phlebectomy, also known as 
stab phlebectomy, ambulatory phlebectomy, or microphlebectomy, involves the removal of secondary smaller 
veins as the removal of the varicose veins are through a small 1-2 mm incision in the skin overlying the vein.
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Covered Indications 
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
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 with the following conditions: 
o Demonstrated perforator reflux >500 msec; AND 
o No saphenous reflux (greater, small, or accessory) and/or symptomatic varicose 
tributaries; AND 
o An active venous ulcer; AND 
o The IPV is at least 3.5 mm in diameter; AND 
o The perforator is in the vicinity of the ulcer. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L39121: Treatment of Varicose 
Veins of the Lower Extremities. 
 
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.