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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 venous duplex ultrasound examination confirms the diagnosis demonstrating the presence 
of venous reflux (>500 milliseconds for superficial or perforator veins; >1000 milliseconds for deep veins). 
A variety of treatment modalities are available to treat varicose veins/chronic venous insufficiency. Treatment 
modalities include conservative management and invasive procedures. 
Conservative Management (Noninvasive procedures) 
Components of conservative therapy should be discussed and individualized to meet the needs of each patient 
and must be documented in the medical record. The discussion should include, but is not limited to: 
 weight reduction 
 exercise plan and prescribed physical activity (walking, treadmill, cycling) 
 periodic leg elevation 
 compressive therapy with use of surgical grade compression stockings (minimum 20-30 mmHg) 
For patients who meet any one of the following criteria, conservative therapy may be waived. 
 C4-C6 disease (skin changes assigned to venous disease, healed venous leg ulceration, and active 
venous leg ulceration) 
 Hemorrhage 
 Recurrent superficial thrombophlebitis 
Invasive procedures 
A) Sclerotherapy: Sclerotherapy is a minimally invasive percutaneous technique using chemical irritants, that 
is, liquid and foam sclerotherapy techniques, to close unwanted veins. Sclerotherapy for treatment of varicose 
veins or reflux is followed by compression therapy of the affected lower limb using either elastic or 
conventional bandaging.  Liquid Sclerosant: 
Liquid sclerotherapy can be used to treat telangiectasias, reticular veins, small varicose veins (3-6 
mm), residual or recurrent veins following endovenous ablation or surgery, and perforator veins. Some 
examples of sclerotherapy agents are polidocanol, hypertonic saline, sodium tetradecyl sulfate, and 
glycerin. 
 Foam Sclerosant: Ultrasound-Guided Foam Sclerotherapy (UGFS): 
Foam sclerotherapy is a procedure that is performed under ultrasound guidance and is a nonthermal 
therapy. The different types of foam are physician-compounded foam (PCF) and non-compounded 
foam (NCF). Foam preparations are used for treatment of symptomatic varicose veins 3 mm. The 
heavier foam is needed to displace the increased volume of blood in these larger veins, which increases 
the contact time of the sclerosant with the vein wall, enhancing the sclerosant effect. Ultrasound-Guided 
Foam Sclerotherapy (UGFS) is used for the treatment of reflux of the superficial axial veins (great 
saphenous vein (GSV), small saphenous vein (SSV), accessory saphenous vein (ASV)), reflux of 
perforator veins, and venous malformations.
 
It is recognized that foam sclerotherapy is not FDA-
approved. However, UGFS has been in use in the United States for more than 20 years and is a standard 
of care for many venous disorders with an excellent safety profile. 
B) Thermal Ablation:  
 Radiofrequency Ablation (RFA), Endovenous Radiofrequency Ablation (ERFA): 
Radiofrequency ablation (RFA) is a minimally invasive percutaneous technique 
using radiofrequency energy and ultrasound guidance to puncture the vein and position a catheter to 
ablate incompetent veins. The device is used primarily to treat insufficiency of the axial veins (i.e., 
great, small, anterior accessory great saphenous veins), but perforator veins can also be treated with a 
specialized radiofrequency stylet. The indications for RFA are the same as for other venous ablation 
techniques.
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Patients with persistent symptoms and signs of superficial venous disease and documented 
axial venous reflux (i.e., retrograde flow >500 ms for superficial or perforator veins) are candidates for 
treatment. The procedure may be performed in an outpatient setting. 
 Endovenous Laser Ablation (EVLA), Endovenous Laser Ablation Therapy (EVLT): 
Endovenous laser ablation (EVLA) is a percutaneous technique that uses laser energy to ablate 
incompetent superficial veins. The axial veins are the primary target for this therapy and include the 
GSV, SSV, and AAGSVs. A relative contraindication to thermal ablation (EVLA and RFA) is severe 
tortuosity of a vein segment in which passage of the device may not be possible. Minimally invasive 
therapies, including RFA and EVLA, provide similar or improved clinical outcomes compared with 
GSV ligation and stripping. 
C) Chemical Adhesive (Cyanoacrylate embolization): 
This nonthermal ablation technique uses a glue delivered into the saphenous vein using a catheter for access 
that induces a foreign body reaction leading to inflammation and fibrotic occlusion of the vessel. It is used for 
the treatment of incompetent saphenous veins (GSV, SSV, AAGSV).
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D) Mechanochemical Ablation (MOCA): 
This nonthermal technique uses both mechanical damage to the vein endothelium with a rotating wire and 
simultaneous chemical injury with installation of a liquid sclerosant to lead to scarring and fibrosis. The most common site of treatment is the GSV. It is used for the treatment of incompetent saphenous veins (GSV, SSV, 
AAGSV). 
E) Surgical: Ligation, Stripping, Phlebectomy: 
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. 
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. 
  
Non-Invasive Venous Studies 
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. 
Limitations 
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 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.