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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 say that Chronic Venous Insufficiency (CVI) is a cause of abnormalities of the venous system 
producing edema, skin changes, or venous ulcers that is associated with varicose veins. Varicose veins of the 
lower extremities are a manifestation of chronic venous disease (CVD) and are a common disorder in the 
United States. They are dilated subcutaneous veins that are greater than or equal to 3 millimeters in diameter 
and have reflux >500 milliseconds in an upright position. They may be caused by primary venous disease with 
local or multifocal structural weakness of the vein wall leading to valvular insufficiency or valvular reflux. 
Secondary causes include a previous deep vein thrombosis, a deep venous obstruction, superficial 
thrombophlebitis, an arteriovenous fistula or a congenital venous malformation. Varicosities are frequently the 
cause of discomfort, pain, disability and deterioration of health-related quality of life (QOL). 
 
Clinical outcome studies evaluate the results of procedures on patient-focused outcomes, including symptom 
improvement, recurrence of varicosity, healing or recurrence of skin ulcers, improvement in the chronic, 
progressive symptoms of CVD/CVI, improved QOL and improved activities of daily living. Patient outcome 
assessments or quality of life instruments can be measured before and after treatment. Below are some 
examples (not all inclusive) of the validated assessment tools: 
 
AVVQ: Aberdeen Varicose Vein Questionnaire 
HASTI: (heaviness, achiness, swelling, throbbing, itching) score 
Veines-QOL: Venous Insufficiency Epidemiological and Economic Study-Quality-of-Life/Symptoms 
CIVIQ-20: Chronic Venous Insufficiency Quality-of-Life Questionnaire 
 
Terminology of veins discussed within this LCD 
 
Superficial, deep and perforating veins make up the lower extremity venous system. Superficial veins, which 
are located between the deep fascia and the skin, include the telangiectasia veins, the reticular veins and the 
main axial (truncal) superficial veins, the great and small saphenous veins and their tributaries. Deep veins, 
which lie beneath the muscular fascia, include the following: inferior vena cava, common iliac, internal iliac, 
external iliac, pelvic, gonadal, broad ligament, common femoral, deep femoral, femoral, popliteal, crural 
(anterior tibial, posterior tibial, or peroneal), and muscular (gastrocnemius, soleus and other).Perforating veins, which penetrate the muscular fascia and connect the superficial and deep veins, include numerous veins from 
those of the foot, the medial and lateral calf, and the thigh. 
 
Telangiectasia veins (also known as spider veins) are small, dilated, flat, thin-walled, blue or red veins <1 
mm in diameter that are seen near the surface of the skin. Reticular veins are a network of veins parallel to the 
skin surface and lying between the saphenous fascia and dermis, which drain the lower extremity skin and 
subcutaneous tissue and have a diameter 1-3 mm (also known as blue veins or feeder veins). 
 
The axial superficial veins communicate with the deep venous system at different locations. The point where 
the great saphenous vein (GSV) joins the common femoral vein, the saphenofemoral junction (SFJ), is located 
proximally at the groin. The point where the small saphenous vein (SSV) joins the popliteal vein, the 
saphenopopliteal junction (SPJ), is typically located behind the knee. Clinically significant reflux can also be 
found in accessory great saphenous veins (i.e., Anterior Accessory Great Saphenous Vein [AAGSV] or 
Posterior Accessory Great Saphenous Vein [PAGSV]) which parallel the GSV in the saphenous compartment, 
the SSV, or perforating veins. The perforator veins drain from the superficial veins toward the deep 
(intramuscular) veins.  Pathologic perforator veins are defined by outward flow duration >500 ms, vein 
diameter >3.5 mm and located underneath skin damage or ulceration.7 Variations in the anatomy of the deep 
and superficial venous systems are common. 
 
The plan of care, for a 90-day episode of care, is based on the treating physicians assessment. The minimum 
evaluation that must be documented includes the history, physical examination, CEAP clinical classification, 
VCSS, and a venous duplex scan documenting the venous flow. 
 
Supplemental plethysmography, contrast venography, venous pressure measurements, intravascular ultrasound 
(IVUS), computed tomography (CT) venography, or magnetic resonance (MR) venography may be relevant to 
the plan of care in patients with severe or unusual presentations of venous disease in which there is possible 
concurrent involvement of pelvic veins or arterial-venous malformations or fistulae. Indications for these more 
extensive procedures should be documented in the plan of care. 
 
Covered Indications 
 
Invasive procedures will be considered medically reasonable and necessary if the patient meets the criteria as 
outlined in this LCD, and the intervention is addressed and supported in the plan of care, for a 90 day episode 
of care, that includes a specific treatment plan determined by the assessment and evaluation of the lower 
extremity venous incompetence. 
Invasive procedures for the treatment of varicose veins are considered medically reasonable and necessary 
when ALL of the following criteria have been met: 
An evaluation of the patient has been performed including a history and physical examination, the CEAP 
clinical classification and the revised Venous Clinical Severity Score (VCSS), AND 
A duplex scan of the deep and superficial venous systems supports the examination findings, AND 
A duplex scan confirms the presence of reversed venous flow (reflux) with provocative maneuvers in the 
saphenous, or perforator veins is 500 milliseconds or greater3 and absence of deep venous obstruction, AND 
The documentation supports signs and/or symptoms that interfere with activities of daily living and/or quality 
of life, AND 
The CEAP clinical classification is C1 to C6 with the following criteria: 
Treatment of C1 disease (telangiectasia and their feeding reticular veins) is considered medically reasonable 
and necessary for patients with spontaneous and/or traumatic venous hemorrhage. 
For patients with C2 or C3 disease and VCSS <6, the plan of care shall include documentation of a period of 
conservative therapy (2 to 4 weeks) including graduated compression 20-30 mmHg or greater, ambulation, 
elevation, and avoiding prolonged sitting and standing. 
For patients who meet any one of the following criteria, the mandatory conservative therapy prior to the 
invasive procedure may be waived. VCSS =6 
C4-C6 disease (skin changes assigned to venous disease, healed venous leg ulceration, and active venous leg 
ulceration) 
Hemorrhage 
Recurrent superficial thrombophlebitis 
Incompetent perforator vein (IPV) management by foam sclerotherapy or thermal ablation, will be considered 
medically reasonable and necessary when: 
An active venous ulcer is in close proximity to the IPV, OR 
The proximal significant reflux has been treated and an IPV persists under or adjacent to a healed venous 
ulcer, OR 
The proximal and regional venous reflux has been treated and there is persisting focal pain and tenderness or 
stasis dermatitis overlying an IPV, OR 
The incompetent perforator demonstrates reflux >500 ms and diameter > 3.5 mm. 
Ultrasound guided foam sclerotherapy (UGFS), physician-compounded foam (PCF) and non-compounded 
foam (NCF) will be considered medically reasonable and necessary for ablation of incompetent saphenous 
veins and tributary veins for the treatment of patients with symptomatic CEAP clinical classification C2 to C6 
disease. UGFS is also considered medically reasonable and necessary for ablation of venous malformations. 
Liquid sclerotherapy will be considered medically reasonable and necessary for ablation of incompetent 
saphenous veins and tributary veins for the treatment of patients with symptomatic CEAP clinical classification 
C2 to C6 disease. Liquid sclerotherapy is also considered medically reasonable and necessary for the treatment 
of patients with symptomatic CEAP clinical classification C1 (telangiectasia and their feeding reticular veins) 
with spontaneous and/or traumatic venous hemorrhage. 
Thermal ablation (radiofrequency or laser) will be considered medically reasonable and necessary for ablation 
of incompetent saphenous veins for the treatment of patients with symptomatic CEAP clinical classification C2 
to C6 disease. 
Chemical adhesives will be considered medically reasonable and necessary for ablation of incompetent 
saphenous veins for the treatment of patients with symptomatic CEAP clinical classification C2 to C6 disease. 
Mechanochemical ablation (MOCA) will be considered medically reasonable and necessary for ablation of 
incompetent saphenous veins for the treatment of patients with symptomatic CEAP clinical classification C2 to 
C6 disease. 
It is the responsibility of the provider to comply with all applicable State and Federal laws related to the human 
use of agents. 
Surgery will be considered medically reasonable and necessary for treatment of incompetent saphenous veins 
for patients with symptomatic CEAP clinical classification C2 to C6 disease. 
Phlebectomy will be considered medically reasonable and necessary for symptomatic bulbous varicosities 
greater than 3mm diameter above and below the knees. If saphenous vein ablation is performed, phlebectomy 
may be staged or concomitant depending upon the vein pattern and/or provider preferences. 
 
You can find these rules in the Local Coverage Determination (LCD) Treatment of Chronic Venous 
Insufficiency of the Lower Extremities L34924. 
 
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.