Local Coverage Determination (LCD)

Varicose Veins of the Lower Extremity, Treatment of

L33575

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Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

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Source LCD ID
N/A
LCD ID
L33575
Original ICD-9 LCD ID
Not Applicable
LCD Title
Varicose Veins of the Lower Extremity, Treatment of
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL33575
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 11/21/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
11/16/2017
Notice Period End Date
12/31/2017

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Issue

Issue Description

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 (telangiectases) are dilated capillary veins that are most often treated for cosmetic purposes.

The accepted treatments for eliminating saphenous (great saphenous vein (GSV), anterior accessory GSV (AAGSV), small saphenous vein (SSV)) reflux (saphenofemoral or saphenopopliteal) are radiofrequency ablation (RFA), laser ablation (EVLA), polidocanol microfoam (PEM), cyanoacrylate embolization (CAE) ablation, and mechanochemical ablation (MOCA). Coverage is only for devices with FDA approval or clearance consistent with saphenous ablation and used according to its approved instructions for use (IFU).

Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Indications:

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 (telangiectases) are dilated capillary veins that are most often treated for cosmetic purposes. 

The accepted treatments for eliminating saphenous (great saphenous vein (GSV), anterior accessory GSV (AAGSV), small saphenous vein (SSV)) reflux (saphenofemoral or saphenopopliteal) are radiofrequency ablation (RFA), laser ablation (EVLA), polidocanol microfoam (PEM), cyanoacrylate embolization (CAE) ablation, and mechanochemical ablation (MOCA). Coverage is only for devices with FDA approval or clearance consistent with saphenous ablation and used according to its approved instructions for use (IFU).

RFA and EVLA are classified as thermal tumescent (TT) techniques; PEM, CAE and MOCA are non-thermal non-tumescent (NTNT) techniques. Each endovenous ablation approach has advantages and disadvantages; which one is best depends on the unique clinical/anatomical scenario. While saphenous vein ligation and stripping remains an important option in selected cases, it has been largely supplanted by endovenous ablation therapy as primary treatment of saphenous (axial/truncal) vein incompetence. The treatments to eliminate the saphenous vein reflux will be considered medically necessary if the patient remains symptomatic after a six-week trial of conservative therapy and has reflux in a saphenous vein.

The treatments for symptomatic varicose tributaries are either compressive sclerotherapy or microphlebectomy. The treatments of the tributary veins will be considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are > than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative therapy.  

The components of the conservative therapy include, but are not limited to:

  • weight reduction,
  • a daily exercise plan,
  • periodic leg elevation, and
  • the use of graduated compression stockings.

The conservative therapy must be documented in the medical record. Inability to tolerate compressive bandages or stockings and the reason for such intolerance must be documented in the medical record.

The patient is considered symptomatic if any of the following signs and symptoms of significantly diseased vessels of the lower extremities are documented in the medical record:

  • stasis ulcer of the lower leg,
  • significant pain and significant edema that interferes with activities of daily living,
  • bleeding associated with the diseased vessels of the lower extremities,
  • recurrent episodes of superficial phlebitis,
  • stasis dermatitis, or
  • refractory dependent edema.

Coverage of endovenous ablation therapy is limited to patients with: 

  • a maximum vein diameter of 12 mm for CAE, PEM and MOCA; and
  • absence of thrombosis or vein tortuosity, which would impair catheter advancement (except for PEM).

Medicare includes payment for the ultrasound guidance in the payment for endovenous ablation procedures.

Limitations:

Coil embolization is non-covered for any varicose vein procedure.

The following interventional treatments are not considered medically reasonable or necessary and are denied as such:

  • Surgery, endovenous ablation, or sclerotherapy are typically not performed for varicose veins that develop or worsen during pregnancy because most will spontaneously resolve or improve after delivery.
  • Reinjection following recanalization or failure of vein closure without recurrent signs or symptoms.
  • Sclerotherapy of the saphenous vein at its junction with the deep system.
  • Noncompressive sclerotherapy.
  • Compressive sclerotherapy for large, extensive or truncal varicosities.
  • Sclerotherapy, ligation and/or stripping of varicose veins, or endovenous ablation therapy are generally not covered for patients with severe distal arterial occlusive disease; obliteration of deep venous system; an allergy to the sclerosant; or a hypercoaguable state.
  • Any interventional treatment that uses equipment or sclerosants not approved for such purposes by the FDA.
Summary of Evidence

Mechanochemical endovenous ablation

The impetus for alternatives to RFA and EVLA is the desire to eliminate the need for thermal energy which necessitates tumescent anesthesia and can cause pain and complications.  

In a randomized control trial (RCT) involving MOCA, the “Venefit™ versus ClariVein for varicose veins trial”, 170 patients with symptomatic saphenous vein insufficiency were randomized to either MOCA or RFA (Bootun 2016, Lane 2016). MOCA was associated with significantly lower procedure related pain, and “occlusion rates, clinical severity scores, disease specific and generic quality of life scores were similar between groups at one and six months.”  

Two non-randomized controlled studies have also been published. Van Eekeren prospectively compared MOCA with RFA in 68 consecutive patients (van Eekeren 2013). The treated great saphenous vein (GSV) was significantly wider at the saphenofemoral junction (SFJ) in the RFA group than in the MOCA group (P=.03). The primary endpoint, postoperative pain, was significantly less for MOCA initially and similar at 6 weeks. A major limitation to the study was that occlusion rates were not reported. The second prospective, non-randomized controlled study compared MOCA (n=57) with RFA (n=50) and EVLA (n=40) (Vun 2014). The MOCA group demonstrated significantly lower procedural pain scores and shorter treatment times, but occlusion rates beyond six weeks were not measured.  

Among the several prospective, non-controlled, cohort studies, the one by Witte has the longest follow-up (Witte 2016). The midterm (median 3 year follow-up) results on a group of 85 consecutive MOCA patients showed an anatomic success rate of 92.8%/89.5%/86.5% at 1/2/3 years, respectively, with a mean GSV diameter of only 5.2mm. Three year clinical success (accounting for return of varicosities between 12 and 36 months was 83%. The authors note: “Between 12 and 36 months, however, a significant deterioration was observed in venous clinical severity score (VCSS), which was accompanied by worsening of disease-specific and general quality of life, and also associated with recurrent varicosities between 12 and 36 months.”  

In the largest multicenter prospective cohort study, 507 limbs in 449 patients were treated for incompetence of GSV or small saphenous vein (SSV) with MOCA (Deijen 2015). Rates of venous closure at 6 weeks and 3 months for GSV were 94.5% and 89%; and for SSV at 6 weeks 85% and 80.5% at 3 months.  

Another prospective, multicenter, observational study of 126 patients treated with MOCA reported 2 year follow-up on 65 patients with a 92% GSV closure rate (Kim 2016). Overall clinical success rate at 2 years was 89%. Average GSV diameter was only 7.6mm. There was significant improvement in Classification for Chronic Venous Disorders (CEAP) and clinical severity scores compared with baseline.  

A single center cohort study of 63 patients (73 limbs) treated with MOCA for GSV insufficiency reported an occlusion rate of 95% at 2 years and an associated significant improvement in VCSS (Ozen 2014). Another cohort study assessed MOCA in 50 patients with insufficiency of the SSV (Boersma 2013). The anatomic success rate was 94% at 1 year, also associated with a significant improvement in VCSS. 

In a recent systematic review (Witte 2017), the short-term pooled anatomical success rate was 92% (n=1314 veins). After 6 and 12 months these numbers were 92% (n-284) and 91% (n=228). The long-term anatomical success rates at 2 and 3 years were 91% (n=136) and 87% (n=48). Another recent systematic review (Kugler 2017) reported early, 1, and 2 year anatomical success ranges of 87-99%, 88-97% and 96-97%, respectively.  

American Venous Forum (AVF) 2017 Guidelines give MOCA a “strong” recommendation for above-knee (AK) GSV treatment for diameters <12mm.

Polidocanol endovenous microfoam (PEM) ablation

There are three randomized controlled trials comparing foam ablation with EVLA and surgery. Brittenden (2014) randomized 798 patients with primary varicose veins. The foam group had worse disease-specific survival after 6 months (p=0.006), and less successful ablation (p<0.001). Biemans (2013) compared the one year outcomes in 240 patients randomized similarly to foam, EVLA, or surgical ablation. While the anatomic success rate was only about 72% with foam compared with about 88% for EVLA and surgical ablation (p<0.001), quality of life and complications were comparable. Rasmussen (2011) randomized 500 patients to EVLA, RF, foam, or surgical ablation had similar results. However, all three RCTs did not involve standardized polidocanol microfoam (PEM).

Three RCTs compare PEM with placebo. The VANISH-1 study (King 2015) randomized 279 patients between five groups, PEM at 3 different concentrations (0.5%, 1%, 2%) and controls (PEM 0.125% and placebo). At week 8, VVSymQ (patient reported venous symptom improvement) was significantly superior to placebo. Occlusion rates were 58.8%, 80.4%, and 82.5% in the 0.5%, 1%, and 2% groups, respectively. The VANISH-2 study (Todd 2015) randomized 232 patients between four groups, PEM at 2 different concentrations (0.5%, 1%) and controls (PEM 0.125% and placebo). The primary endpoint at 8 weeks of improved VVSymQ was similar to the VANISH-1 study, and was maintained at one year (n=221). Occlusion rates were 89% and 73% at 8 weeks and one year, respectively. Gibson (2016) randomized 77 patients and found PEM provided significantly greater symptom relief and improvement in leg appearance compared with placebo. Anatomic success was 90% at 4 weeks. 

Four meta-analyses (van den Bos 2009, Nesbitt 2014, Carroll 2014, Demody 2015) all conclude that there is little to choose between surgery and newer minimally invasive techniques (foam, laser, RF ablation) in terms of either efficacy or safety.

Recent systematic review articles (Davies 2016, Kugler 2017) suggest improved anatomic success after EVLA as measured by duplex ultrasound; however, overall clinical outcomes and safety are similar between laser and foam ablation.

American Venous Forum (AVF) 2017 Guidelines give PEM a “strong” recommendation for above-knee (AK) GSV treatment for diameters <12mm.

Cyanoacrylate embolization (CAE) ablation 

Cyanoacrylate embolization (CAE) ablation received FDA PMA approval on 2/20/15 to treat superficial leg varicosities via endovascular embolization. CPT codes for CAE for the treatment of incompetent veins become effective 1/1/18. CAE is the only non-sclerosant NTNT for symptomatic venous reflux and is also unique in not requiring post-procedure compression. The polymerized adhesive chemically bonds to the apposed intimal walls of the vein, effectively embolizing the vein by immediate closure. A foreign body reaction incites an inflammatory response in the vessel, ultimately leading to fibrotic occlusion. 

The 3 year results of a single-center, prospective feasibility study were recently reported (Almeida 2017). Inclusion criteria included symptomatic GSV incompetence (CEAP stage C2-C4). No post-procedure compression was used. Among the 29 subjects (of 38 initially treated), the 36 month occlusion rate was 94.7%, and the mean VCSS improved from 6.2 to 2.2 (p<.0001).  

The European multicenter eSCOPE prospective study of 70 patients with symptomatic GSV incompetence (CEAP stage C2-C4) demonstrated a one year anatomic success rate (N=68) of 92.9% (Proebstele 2015). Statistically significant clinical outcomes paralleled anatomic success as measured by VCSS as well as patient-rated disease-specific Aberdeen Varicose Vein Questionnaire (AVVQ) and European Quality of Life 5 dimensions questionnaire (EQ-5D). Adverse events were generally mild and self-limited. 

The VenaSeal Sapheon Closure System (VeClose) non-inferiority pivotal trial randomized 222 patients with symptomatic GSV incompetence (CEAP stage C2-C4) to either CAE (108) or RFA (114) (Morrison 2017). This trial did use post-operative compression as a fair comparison to RFA. Twelve month follow-up in 192 (95 CAE and 97 RFA), demonstrated a nearly identical complete occlusion rate in both groups (97.2% CAE and 97% RFA), demonstrating non-inferiority of CAE compared with RFA (p<.0001). Symptom improvement, as measured by VCSS, AVVQ, and EQ-5D were similar in both groups, as were adverse events.

American Venous Forum (AVF) 2017 Guidelines give CAE a “strong” recommendation for above-knee (AK) GSV treatment for diameters <12mm. 

Analysis of Evidence (Rationale for Determination)

Mechanochemical endovenous ablation 

In summary, the study data, including an RCT, consistently demonstrates relative parity with thermal ablation techniques in terms of anatomic success, at least in small to medium axial veins, but with less pain and complications. The amount and consistency of the data, in addition to the two recent systematic reviews and the “strong” recommendation by the American Venous Forum (AVF), the US’s major venous society, have convinced NGS that Medicare coverage criteria is met for MOCA as an alternative to current ablation standard of care techniques.

Polidocanol endovenous microfoam (PEM) ablation 

In summary, although anatomical success appeared slightly higher with endothermal ablation than foam, clinical success as measured by physician-derived and patient-reported outcomes measures appear similar, at least for the standardized polidocanol microfoam (PEM) preparation in small to medium axial veins. Anatomic success (closure or presence of reflux) may lack sensitivity in that it’s a binary response (ignores whether any small residual reflux is physiologically important). Re-canalisation may not lead to return of symptoms or need for further intervention (Theivacumar 2008). According to AVF Guidelines, “the idea of the occlusion rate being the primary endpoint has faded in recent years,” replaced by quality of life. In fact, the FDA seems to favor assessing treatment benefit in terms of patient-reported outcome (PRO) over surrogate measures “that do not directly capture the treatment effect on how a patient survives, feels, or functions.”  

The combination of the RCTs, meta-analyses, systematic reviews, the “strong” recommendation by the American Venous Forum (AVF), and written endorsement by a coalition of other vascular societies (Society of Vascular Surgery (SVS), American college of Phlebology (ACP), Society for Cardiovascular Angiography and Interventions (SCAI), and Society of Interventional Radiology (SIR)), have convinced NGS that Medicare coverage criteria is met for PEM as an alternative to current ablation standard of care techniques. 

Cyanoacrylate embolization (CAE) ablation

In summary, the study data, especially the non-inferiority RCT with RFA, the current standard of care, demonstrates relative parity with thermal ablation techniques in terms of anatomic success and quality of life measures, at least in small to medium veins. In addition, the “strong” recommendation by the American Venous Forum (AVF), and written endorsement by a coalition of other vascular societies (Society of Vascular Surgery (SVS), American college of Phlebology (ACP), Society for Cardiovascular Angiography and Interventions (SCAI), and Society of Interventional Radiology (SIR)), have convinced NGS that Medicare coverage criteria is met for CAE as an alternative to current ablation standard of care techniques.

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Bibliography

This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.

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Theivacumar NS, Gough MJ. Influence of warfarin on the success of endovenous laser ablation (EVLA) of the great saphenous vein (GSV). Eur J Vasc Endovasc Surg. 2009;38(4):506-510.

Theivacumar NS, Dellagrammaticas D, Darwood RJ, Mavor AI, Gough MJ. Fate of the great saphenous vein following endovenous laser ablation: does re-canalisation mean recurrence? Eur J Vasc Endovasc Surg. 2008;36:211-5.

Thibault P. Sclerotherapy and ultrasound-guided sclerotherapy: The Vein Book. London U. Elsevier Academic Press; 2007:189-199.

Todd KL, Wright DI and the VANISH-2 Investigator. Group. Durability of treatment effect with polidocanol endovenous microfoam on varicose vein symptoms and appearance (VANISH-2). J Vasc Surg Venous Lymphat Disord. 2015:3(3):258-264 e251.

Todd KL III, Wright DI, Gibson K, et al. The VANISH-2 study: a randomized, blinded, multicenter study to evaluate the efficacy and safety of polidocanol endovenous microfoam 0.5% and 1.0% compared with placebo for the treatment of saphenofemoral junction incompetence. Phlebology. 2014;29(9):608-618.

Trelles M. The 800-nm diode laser in the treatment of leg veins: Assessment at 6 months. Journal of American Academy of Dermatology. 54(2).

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Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
11/21/2019 R11

Disabled web link in Bibliography

  • Typographical Error
11/21/2019 R10

Corrected link in Bibliography for FDA 510(k) Clarivein approval. http://www.accessdata.fda.gov/cdrh_docs/pdf7/k071468.pdf  

  • Typographical Error
11/21/2019 R9

This LCD was converted to the new "no-codes" format. There has been no change in coverage with this LCD revision.

  • Revisions Due To Code Removal
08/01/2019 R8

Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A52870. There has been no change in coverage with this LCD revision.

  • Provider Education/Guidance
01/01/2018 R7 Added CPT codes 36465, 36466, 36482 and 36483 to the table in “CPT/HCPCS Codes” section. The explanatory note was revised accordingly.
  • Other
01/01/2018 R6

The LCD was submitted to Jurisdiction 6 and Jurisdiction K for public and CAC comment from 06/19/2017 through 08/02/2017.

Based on the comments and peer-reviewed literature received, the changes shown below were made:

The paragraphs shown below were added to the "Indications" section:

The accepted treatments for eliminating saphenous (great saphenous vein (GSV), anterior accessory GSV (AAGSV), small saphenous vein (SSV)) reflux (saphenofemoral or saphenopopliteal) are radiofrequency ablation (RFA), laser ablation (EVLA), polidocanol microfoam (PEM), Cyanoacrylate embolization (CAE) ablation, and mechanochemical ablation (MOCA). Coverage is only for devices with FDA approval or clearance consistent with saphenous ablation and used according to its approved instructions for use (IFU).

RFA and EVLA are classified as thermal tumescent (TT) techniques; PEM, CAE and MOCA are non-thermal non-tumescent (NTNT) techniques. Each endovenous ablation approach has advantages and disadvantages; which one is best depends on the unique clinical/anatomical scenario. While saphenous vein ligation and stripping remains an important option in selected cases, it has been largely supplanted by endovenous ablation therapy as primary treatment of saphenous (axial/truncal) vein incompetence. The treatments to eliminate the saphenous vein reflux will be considered medically necessary if the patient remains symptomatic after a six-week trial of conservative therapy and has reflux in a saphenous vein.

The treatments for symptomatic varicose tributaries are either compressive sclerotherapy or microphlebectomy. The treatments of the tributary veins will be considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are > than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative therapy.

Coverage of endovenous ablation therapy is limited to patients with: 

  • a maximum vein diameter of 12 mm for CAE, PEM and MOCA;
  • absence of thrombosis or vein tortuosity, which would impair catheter advancement (except for PEM); and
  • absence of significant peripheral artery disease.

The following limitation was revised to include "generally":

Sclerotherapy, ligation and/or stripping of varicose veins, or endovenous ablation therapy are generally not covered for patients with severe distal arterial occlusive disease; obliteration of deep venous system; an allergy to the sclerosant; or a hypercoaguable state.

The following information was added to the explanatory note in the "CPT/HCPCS Codes" section:

CPT codes 36468, 36470 and 36471 were revised effective January 1, 2018. The new CPT codes are 36465, 36466, 36482 and 36483. 

New CPT codes for describing the injection procedure for Varithena® will be available January 1, 2018: 

36465 - Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (e.g., great saphenous vein, accessory saphenous vein)  

36466 - Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (e.g., great saphenous vein, accessory saphenous vein), same leg 

Also, the September-October 2016 CPT Editorial Summary of Panel Actions has accepted the addition of CPT codes for cyanoacrylate for the treatment of incompetent veins. These codes below become effective on January 1, 2018. 

36482 - Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated). 

36483 - Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) 

CPT codes 36465, 36466, 36482 and 36483 were added to the explanatory notes in the “ICD-10-CM Codes that Support Medical Necessity” and the “ICD-10-CM Codes that DO NOT Support Medical Necessity” sections.

The following paragraph was added to the "Utilization Guidelines" section:

During a single episode of treatment, most patients with C2, C3 and C4a disease require no more than one ablation of one of the GSV, AAGSV, and SSV per leg and nearly all patients require no more than two of these veins to be treated in each lower extremity during an episode of care. Utilization will be monitored statistically and outlier practitioners may be required to submit medical records for audit.

Additional references were included in the "Bibliography" section.

  • New/Updated Technology
01/01/2017 R5 Due to annual HCPCS update, the descriptor was changed for CPT codes 36476 and 36479.
  • Revisions Due To CPT/HCPCS Code Changes
12/01/2016 R4 The following statement was added to the explanatory note in the “ICD-10-CM Codes that DO NOT Support Medical Necessity” section:

In addition, the ICD-10-CM codes listed below are specifically included as not supporting medical necessity for emphasis, and to avoid any provider errors.
  • Provider Education/Guidance
11/01/2016 R3 Based on a reconsideration request, eight (8) references were added to the “Sources of Information and Basis for Decision” section. It was determined Medicare coverage criteria are not yet met for Varithena® as an alternative to current saphenous vein excision or ablation standard of care techniques.
  • Reconsideration Request
01/01/2016 R2 References to CPT codes 76942, 93965, 93970 and 93971 were removed from the “Limitations”, “CPT/HCPCS Codes”, “ICD-10-CM Codes that Support Medical Necessity” and “Utilization Guidelines” sections. Refer to the Non-Invasive Vascular Studies LCD (L33627) for coverage criteria on imaging guidance.
  • Provider Education/Guidance
10/01/2015 R1 Revised verbiage in the “Abstract” section for foam sclerotherapy of the saphenous vein at its junction with the deep venous system to state that it lacks “sufficient” rather than “significant” evidence to support its widespread use. Added two (2) references to the “Sources of Information and Basis for Decision” section.

Based on a reconsideration request, the following statements were added to the “Indications” section:

Inability to tolerate compressive bandages or stockings and the reason for such intolerance must be documented in the medical record.

Surgery, EFRA and laser ablation, or sclerotherapy are typically not performed for varicose veins that develop or worsen during pregnancy because most will spontaneously resolve or improve after delivery.

The non-coverage for sclerotherapy, ligation and/or stripping of varicose veins, or endovenous ablation therapy for pregnant women and patients on anti-coagulant therapy was removed from the “Limitations” section. The non-coverage for “patients with the inability to tolerate compressive bandages or stockings” was also removed from this section.

Five (5) references were added to the “Sources of Information and Basis for Decision” section.

Minor template language change.
  • Reconsideration Request
  • Other
N/A

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Keywords

  • Varicose veins
  • Telangiectasia
  • Spider veins
  • Cosmetic
  • Ligation and stripping
  • Endovenous radiofrequency ablation (EFRA)
  • Laser ablation

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