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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 endoluminal radiofrequency ablation (ERFA) and endoluminal laser ablation have been 
developed as alternatives to sclerotherapy and surgical intervention. These procedures are designed to damage 
the intimal wall of the vein resulting in fibrosis and subsequent ablation of the lumen of a segment of the 
vessel. Both procedures utilize specially designed catheters inserted through a small incision in the distal thigh 
and advanced, often under ultrasound guidance, nearly to the saphenofemoral junction. The catheter is then 
slowly withdrawn while controlled radiofrequency or laser energy is applied. This is followed by external 
compression of the treated segment. 
 
Doppler ultrasound or duplex studies are often used to map the anatomy of the venous system prior to the 
procedure. There is adequate evidence that pre-procedural ultrasound is helpful, and Medicare will cover one 
ultrasound or duplex scan prior to the procedure to determine the extent and configuration of the varicosities 
when it is medically necessary. 
 
Evidence and clinical experience support the use of ultrasound guidance during the procedure, and show that 
the outcomes may be improved and complication rates may be minimized when ultrasound guidance is used. 
The CPT codes for radiofrequency and laser include the intra-operative ultrasound service in the evaluation, 
and ultrasound may not be billed separately with these procedures. 
 
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. 
 
    Indications for surgical treatment and sclerotherapy: 
        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 
        The patient is symptomatic and has one, or more, of the following: 
            Pain, aching, cramping, burning, itching and/or swelling during activity or after prolonged standing 
severe enough to impair mobility 
            Recurrent episodes of superficial phlebitis             Non-healing skin ulceration 
            Bleeding from a varicosity 
            Stasis dermatitis 
            Refractory dependent edema 
        The treatment of spider veins/telangiectasis will be considered medically necessary only if there is 
associated hemorrhage. 
    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: 
        Absence of aneurysm in the target segment. 
        Maximum vein diameter of 20 mm for ERFA or 30 mm for laser ablation. 
        Absence of thrombosis or vein tortuosity, which would impair catheter advancement. 
        The absence of significant peripheral arterial diseases. 
    Limitations for ERFA and laser ablation: 
        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. 
        Intra-operative ultrasound guidance is not separately payable with ERFA, laser ablation. 
        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. 
        The treatment of spider veins or superficial telangiectasis by any technique is also considered cosmetic, 
and therefore not covered unless there is associated bleeding. 
        Coverage is only for devices specifically FDA-approved for these procedures. 
        One pre-operative Doppler ultrasound study or duplex scan will be covered. 
        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 information in the Local Coverage Determination (LCD) 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.