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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say 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 (greater than 500 msec). 
 
    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) (less than 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. 
    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 (greater than 500 msec), and ANY of the following signs or symptoms: 
        ulceration secondary to venous stasis; 
        significant pain or significant edema associated with saphenous reflux that interferes with activities of 
daily living (ADLs); 
        bleeding associated with ruptured superficial varicosity; 
        recurrent episodes of superficial phlebitis; 
        stasis dermatitis; 
        refractory dependent edema 
    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. 
 
You can find this information in Medicare's 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.