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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 417.414. 
 
The rules state that Varicose veins are caused by venous insufficiency as a result of valve reflux 
(incompetence). The venous insufficiency results in dilated, tortuous, superficial vessels that protrude from the 
skin of the lower extremities. Spider veins (telangiectasias) are dilated capillary veins that are most often 
treated for cosmetic purposes. Treatment of telangiectasias is not covered by Medicare. Historically, varicose 
veins have been treated by conservative measures such as exercise, periodic leg elevation, weight loss, 
compressive therapy and avoidance of prolonged immobility. When conservative measures are unsuccessful, 
and symptoms persist, the next step has been sclerotherapy or surgical ligation with or without stripping. 
Sclerotherapy involves the injection of a sclerosing solution into the varicose vein(s). 
 
Compressive sclerotherapy is the injection of the sclerosant into an empty vein (elevated limb) followed by 
application of a compressive bandage or dressing. This is the most commonly performed sclerotherapy 
procedure for varicose veins of the lower extremity. Compressive sclerotherapy is indicated for local small to 
medium symptomatic varices, isolated incompetent perforators, or recurrence of symptomatic varices after 
adequate surgical removal of varices. It is not considered an appropriate option for large, extensive or truncal 
varicosities. Foam sclerotherapy is FDA indicated for the treatment of incompetent great saphenous veins, 
accessory saphenous veins and visible varicosities of the great saphenous vein (GSV) system above and below 
the knee. It is usually given with ultrasound guidance. Non-Compressive sclerotherapy is not covered by 
Medicare. 
 
More recently, 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. 
 
Evidence and clinical experience supports the use of ultrasound guidance during the procedure (ERFA and 
laser ablation only) and shows 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 intraoperative 
ultrasound service in the valuation and ultrasound may not be billed separately with these procedures. 
 
In contrast to ERFA and laser procedures, intra-operative ultrasound guidance techniques have not been shown 
to increase the effectiveness or safety of sclerotherapy for varicose veins, therefore, intra-operative ultrasound 
guidance will not be separately covered for sclerotherapy. 
 
A. Indications for surgical treatment: For example venous ligation, vein stripping and/or sclerotherapy. 
 
1. 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 
 
2. The patient is symptomatic and has one, or more, of the following: 
a. Pain or burning in the extremity severe enough to impair mobility 
b. Recurrent episodes of superficial phlebitis 
c. Non-healing skin ulceration 
d. Bleeding from a varicosity 
e. Stasis dermatitis 
f. Refractory dependent edema 
 
B. 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: 
 
1. Absence of aneurysm in the target segment. 
2. Maximum vein diameter of 12 mm for ERFA or 20 mm for laser ablation 
3. Absence of thrombosis or vein tortuosity, which would impair catheter advancement. 4. The absence of 
significant peripheral arterial diseases. 
 
C. Limitations for ERFA and laser ablation: 
1. 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. 
2. Intra-operative ultrasound guidance is not separately payable with ERFA, laser ablation, and sclerotherapy. 
3. 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. 
4. The treatment of spider veins or superficial telangiectasis by any technique is considered cosmetic, and 
therefore not covered. 
5. Coverage is only for devices specifically FDA-approved for these procedures. 
6. One pre-operative Doppler ultrasound study or duplex scan will be covered. 
Noridian notes that 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. 
 
Noridian notes that if sclerotherapy is used with endovenous radiofrequency ablation, it may be covered if the 
criteria for reasonable and necessary as described in this LCD are met. 
 
Noridian will not consider the treatment of asymptomatic veins with endoluminal ablation or sclerotherapy 
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 rule in the Medicare Local 
Coverage Determination (LCD)- L34010, 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.