Commercial

Medical Policy

Notification

Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence

Notification Issued Date:

This version of the policy will become effective 01/13/2025.

A medically necessary coverage statement was added for foam sclerotherapy and cyanoacrylate adhesive. Experimental/investigational statements were added for catheter-assisted vein sclerotherapy with ballon isolation, sclerotherapy of perforator veins and sclerotherapy techniques, other than microfoam of saphenous veins.
The coverage position for the following code was revised from Cosmetic to Medically Necessary: 36468. The coverage position for the following codes was revised from Experimental/Investigational to Medically Necessary: 36482, 36483. The coverage position for the following code was revised from Not Medically Necessary to Medically Necessary: S2202 Echosclerotherapy.
The following NOC code was added to the policy to represent stab phlebectomy fewer than 10 incisions: 37799 (Medically Necessary).
A coding/billing requirement to provide direction on correct coding for sclerotherapy treatment of tributaries and physician compounded foam was added.

Title:

Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence

Policy #:

11.02.01u

Policy

MEDICALLY NECESSARY

GREAT OR SMALL SAPHENOUS VEINS AND/OR DUPLICATE GREAT SAPHENOUS VEINS
Surgery (i.e., Stripping and Ligation), Endovenous Thermal (Radiofrequency or Laser) Ablation Therapy, Microfoam Sclerotherapy, or Cyanoacrylate Adhesives

The treatment of symptomatic great or small saphenous varicose veins/chronic venous insufficiency by surgery (i.e., stripping and ligation), endovenous thermal ablation (radiofrequency or laser), microfoam sclerotherapy, or cyanoacrylate adhesives is considered medically necessary and, therefore, covered when ALL of the following criteria are met:

Documented evidence of one or more of the following symptomatic conditions:
- Nonhealing ulceration secondary to venous stasis
- Recurrent superficial thrombophlebitis in dilated incompetent veins or clusters
- Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity
- Persistent pain, swelling, itching, burning, or other symptoms are associated with saphenous reflux and the symptoms significantly interfere with activities of daily living (e.g., mobility) and documented 3-month trial of conservative medical management has not improved symptoms (see Guidelines section).
Assessment of the lower extremity venous system by duplex studies that show the anatomy and tortuosity of the great and small saphenous vein, within the past 12 months. These studies must demonstrate ALL of the following:
- Presence and patency of the deep venous system
- Absence of large chronic thrombosis
- Great and/or small saphenous vein incompetence/reflux (i.e., reflux >0.5-second duration) that correlates with the section of the leg where the individual has symptoms (e.g., proximal, mid, distal thigh or calf), but not solely saphenofemoral or saphenopopliteal reflux).

ACCESSORY SAPHENOUS VEINS
Surgery (Stripping and Ligation), Endovenous Radiofrequency or Laser Ablation, Microfoam Sclerotherapy or Cyanoacrylate Adhesive

The treatment of symptomatic accessory saphenous varicose veins/chronic venous insufficiency by surgery (stripping and ligation), endovenous radiofrequency or laser ablation, microfoam sclerotherapy followed by compression or cyanoacrylate adhesive is considered medically necessary and, therefore, covered when ALL of the following criteria are met:

Incompetence of the accessory saphenous vein is isolated or if the accessory saphenous vein is still incompetent after the great saphenous vein has been eliminated.
Documented evidence of one or more of the following symptomatic conditions:
- Nonhealing ulceration secondary to venous stasis adjacent to an identified incompetent varicosity
- Recurrent superficial thrombophlebitis in dilated incompetent veins or clusters
- Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity
- Persistent pain, swelling, itching, burning, or other symptoms are associated with saphenous reflux and the symptoms significantly interfere with activities of daily living (e.g., mobility and documented 3-month trial of conservative medical management has not improved symptoms (see Guidelines section).
Assessment of lower extremity venous system by duplex ultrasound studies that show the anatomy and tortuosity of the accessory saphenous vein within the past 12 months.

Concurrent treatment of the accessory saphenous veins along with the great or small saphenous veins may be considered medically necessary when criteria are met for each vein and there is documentation of anatomy showing that the accessory saphenous vein only discharged directly into the common femoral vein.

SAPHENOFEMORAL JUNCTION OR SAPHENOPOPLITEAL JUNCTION
Stripping and ligation is considered medically necessary and, therefore, covered in combination with sclerotherapy with injectable liquid or foam and compression for ligation of the saphenofemoral junction or the saphenopopliteal junction, to treat large varicose veins or clusters not amenable to sclerotherapy or endovenous obliteration techniques.

SYMPTOMATIC VARICOSE TRIBUTARIES

The following treatments are considered medically necessary for the treatment of symptomatic varicose tributaries when performed either in conjunction with another procedure or following prior treatment of the great or small saphenous veins or accessory saphenous veins.

Stab avulsion
Hook phlebectomy
Sclerotherapy, including ultrasound guided foam sclerotherapy (UGFS)
Transilluminated powered phlebectomy (e.g., TriVex system)

PERFORATOR VEINS
Subfascial Endoscopic Perforator Vein Surgery (SEPS), Endovenous Radiofrequency or Laser Ablation

Subfascial endoscopic perforator vein surgery (SEPS) and endovenous radiofrequency or laser ablation of perforator vein incompetence is considered medically necessary and, therefore, covered as a treatment of leg ulcers associated with chronic venous insufficiency when ALL of the following criteria are met:

Duplex ultrasound studies of the venous system demonstrate perforator vein reflux (i.e., reflux >0.5 second duration) that correlates with the individual's symptoms.
The superficial saphenous veins (great, small, accessory saphenous and symptomatic varicose tributaries) have been previously eliminated.
Nonhealing ulceration following combined superficial vein treatment and 3 months of compression therapy.
The venous insufficiency is not secondary to large chronic thromboembolism.

TELANGIECTASIA /SPIDER VEIN/ RETICULAR VEIN
Treatment of telangiectasia (spider veins) and their feeding reticular veins by sclerotherapy with injectable liquid or ultrasound-guided microfoam followed by compression are considered medically necessary and, therefore, covered on an individual basis only if there is associated spontaneous and/or traumatic venous hemorrhage.

EXPERIMENTAL INVESTIGATIONAL

ENDOVENOUS RADIOFREQUENCY OR LASER ABLATION OF TRIBUTARY VEINS
Endovenous radiofrequency or laser ablation of tributary veins are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of these services cannot be established by review of the available published peer-reviewed literature.

AMBULATORY HOOK PHLEBECTOMY/STAB AVULSION OR TIPP OF PERFORATOR, GREAT SAPHENOUS OR SMALL SAPHENOUS VEINS OR ACCESSORY SAPHENOUS VEINS
Ambulatory hook phlebectomy/stab avulsion, or TIPP, of perforator, great or small saphenous veins, or the accessory saphenous veins are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of these services cannot be established by review of the available published peer-reviewed literature.

SCLEROTHERAPY OF ISOLATED TRIBUTARY VEINS
Sclerotherapy of isolated tributary veins without prior or concurrent treatment of saphenous veins is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

CATHETER-ASSISTED VEIN SCLEROTHERAPY (KAVS) WITH BALLOON ISOLATION

Catheter-assisted vein sclerotherapy (KAVS) with ballon isolation is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

SCLEROTHERAPY TECHNIQUES OTHER THAN MICROFOAM SCLEROTHERAPY OF GREAT, SMALL, OR ACCESSORY SAPHENOUS VEINS

Sclerotherapy techniques other than microfoam sclerotherapy, of great, small, or accessory saphenous veins are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of these services cannot be established by review of the available published peer-reviewed literature.

SCLEROTHERAPY OF PERFORATOR VEINS

Sclerotherapy of perforator veins is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

ENDOVENOUS MECHANOCHEMICAL ABLATION OF ANY VEIN
Endovenous mechanochemical ablation (e.g., ClariVein® Infusion Catheter) of any vein is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

ENDOVENOUS CRYOABLATION OF ANY VEIN

Endovenous cryoablation of any vein is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of available published peer-reviewed literature.

COSMETIC

TREATMENT OF ASYMPTOMATIC VARICOSE VEINS
The treatment of asymptomatic varicose veins of the lower extremities using the procedures described above are not covered by the Company because they are a cosmetic service. In addition, any sclerosing agent used in the treatment of asymptomatic varicose veins of the lower extremities is also considered cosmetic. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

TREATMENT OF TELANGIECTASIA (SPIDER VEINS)
The treatment of telangiectasia (spider veins) without the presence of spontaneous and/or traumatic venous hemorrhage, which does not meet the policy criteria above is not covered by the Company because it is a cosmetic service. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

TRAINING AND CERTIFICATION REQUIREMENTS

Refer to the Professional Provider Credentialing requirements located on the Company’s website for information on vein centers accreditation for participation in our network.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The individual's medical record must document the following:

Clear and definitive history and physical that describes the symptoms and physical characteristics of varicose veins
Description of and failure of an adequate trial of conservative treatment (documentation must show at least a 3-month trial and documented individual compliance)
Exclusion of other causes of edema, ulceration, and pain in the limbs and description of clinical steps taken to exclude same
Performance of and results of appropriate tests (including required ultrasonic examination) to confirm the presence and location of incompetent perforating veins

All requests for the treatment of varicose veins or perforator vein incompetence require review by the Company.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, treatment of varicose veins of the lower extremities and perforator vein incompetence is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in the medical policy are met.

Services that are experimental/investigational or cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

CONSERVATIVE MEDICAL MANAGEMENT THERAPY

Conservative medical management therapy refers to the nonsurgical management of varicose veins, which includes the use of graduated compression stockings or wraps, periodic leg elevation, weight reduction as appropriate, mild exercise, avoidance of long periods of standing, and analgesia for symptom relief. Leg elevation helps venous return and decreases venous hypertension.

Compression stockings are defined as graduated elasticized compression stockings. Use of nongraduated compression garments such as support pantyhose does not fulfill this requirement. Lack of compliance with compression stockings does not support the need for intervention without documentation of other failed conservative treatments as well. Compression therapy is an important adjunct for individuals with advanced signs of venous insufficiency, especially those with edema, skin changes, and venous stasis ulcers (C3-C6).

CLINICAL-ETIOLOGY-ANATOMY-PATHOPHYSIOLOGY (CEAP) CLASSIFICATION

The standard classification of venous disease is the Clinical, Etiologic, Anatomic, Pathophysiologic (CEAP) classification system. The C component of CEAP is the clinical signs. Each clinical class is subcharacterized by a subscript that indicates the presence (symptomatic [S]) or absence (asymptomatic [A]) of symptoms attributable to venous disease. The visible signs of chronic venous disorders are categorized as C0 to C6r depending on the appearance and are defined as:

C0: No visible or palpable signs of venous disease
C1: Telangiectasias/reticular veins
C2: Varicose veins
C2r: Recurrent Varicose veins
C3: Edema
C4: Changes in skin and subcutaneous tissue secondary to CVD
C4a: Pigmentation or eczema
C4b: Lipodermatosclerosis or atrophie blanche
C4c: Corona phlebectatica
C5: Healed venous ulcer
C6: Active venous ulcer
C6r: Recurrent active venous ulcer
S: Symptomatic
A: Asymptomatic

US FOOD AND DRUG ADMINISTRATION (FDA)

The FDA approved the marketing of the VNUS Closure® System in March 1999; since 2002, various other laser systems (e.g.,

Diomed 810-nm surgical laser) have also been approved.

In October 2003, the FDA approved the marketing of the Smith+Nephew

TriVex System, which is indicated for use in ambulatory phlebectomy procedures for the resection and ablation of varicose veins.

In March 2008, the FDA approved the marketing of the Vascular Insights

ClariVein™ Infusion Catheter, which is indicated for use in the infusion of specified agents in the peripheral vasculature.

Subfascial endoscopic perforator surgery (SEPS) as a procedure is not regulated by the FDA. However, the FDA has approved several devices for use in a variety of minimally invasive procedures (such as SEPS) to facilitate grasping, mobilization, dissection, and transaction of tissue.

There are numerous products approved by the FDA as

sclerosing agents. For example, sodium

tetradecyl sulfate (

Sotradecol®) was approved by the FDA in 2004 to treat small uncomplicated varicose veins of the lower extremities that show simple dilation with competent valves, and

polidocanol (

Asclera®) was approved by the FDA in 2010 as a

sclerosing agent indicated to treat uncomplicated spider veins (varicose veins ≤1 mm in diameter) and uncomplicated reticular veins (varicose veins 1–3 mm in diameter).

Varithena® (formerly

Varisolve) was approved by the FDA under a new drug application in November 2013 for the treatment of incompetent great saphenous veins, accessory saphenous veins, and visible varicosities of the great saphenous vein system above and below the knee.

Varithena is a

sclerosant

microfoam made with a proprietary gas mix.

The VenaSeal® closure system was approved by the FDA in February 2015 for the permanent closure of lower extremity superficial truncal veins, such as the great saphenous vein (GSV), through endovascular embolization with

coaptation.

BILLING GUIDELINES

Conservative medical management, including, but not limited to, weight reduction programs and support hose may be a benefit contract exclusion. Individual benefits must be verified.

Description

VARICOSE VEINS OF THE LOWER EXTREMITIES

The venous system of the lower extremities consists of deep and superficial veins. The deep venous system consists of the popliteal and femoral veins. The superficial venous system consists of great and small saphenous veins, accessory veins, and rare variant duplicate great saphenous veins (GSVs; veins that travel in parallel with the great and small saphenous veins). Perforator veins cross through the fascia and connect these deep and superficial systems. One-way valves are present at the junction between the bifurcation point of the two systems (i.e., the saphenofemoral and the saphenopopliteal junction). Varicose veins are dilated, tortuous, superficial vessels that result from defective valves within the saphenous veins, from intrinsic weakness of the vein wall, from high intraluminal pressure, or, on rare occasions, from arteriovenous fistulas. Varicose veins of the lower extremities protrude from the skin surface in a rope-like manner.

Many varicose veins are asymptomatic. However, when present, symptoms of varicose veins of the lower extremities include pain, aching, burning, cramping, itching, and/or swelling. Varicose veins of the lower extremities may be complicated by peripheral edema due to venous insufficiency, hemorrhage, or thrombophlebitis. Additional complications may include venous ulceration, chronic skin ulceration, and skin changes.

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 vein. The term "varicose veins" does not include telangiectatic dermal vessels (e.g., "spider veins" or "broken blood vessels"). Spider veins (also known as telangiectases) are small, dilated, flat, thin-walled, blue or red veins smaller than 1 mm in diameter and have a web-like appearance on the surface of the skin. The primary difference between spider veins and varicose veins is that spider veins primarily lack varicose vein symptomatology. Treatment of these superficial veins is usually provided for cosmetic reasons. Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function. In rare incidences, telangiectases may have spontaneous and/or traumatic venous hemorrhages. Sclerotherapy has been proposed as a treatment option for hemorrhagic telangiectases.

Varicose veins are initially treated by conservative medical methods such as graduated, elastic compression stockings, mild exercise, periodic leg elevation, avoidance of long periods of standing, weight loss as appropriate, and analgesia for symptom relief. Additional treatment options may include surgery (i.e., stripping and ligation), endovenous thermal (radiofrequency or laser) ablation therapy, stab avulsion or hook phlebectomy, sclerotherapy, both with injectable liquid and microfoam, including with ultrasound-guided transilluminated powered phlebectomy (TIPP), and subfascial endoscopic perforator surgery (SEPS), and cyanoacrylate adhesive.

CLINICAL-ETIOLOGY-ANATOMY-PATHOPHYSIOLOGY CLASSIFICATION
Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification of lower extremity chronic venous disorders has been developed to serve as a basis for standardized reporting. It classifies lower extremity venous disease based on clinical signs, etiology, anatomic location, and pathophysiologic abnormality.

The visible signs of chronic venous disorders are categorized as a class 0 (no visible sign of disease) to class 6 (active ulceration).

TREATMENT OF VARICOSE VEINS
Stripping and Ligation

Stripping and ligation involves tying off and removing the great or small saphenous vein and its tributaries. Most of the visible varicosities can then be removed either by multiple incisions, with the use of cyanoacrylate adhesive, or by sclerotherapy.

Endovenous Thermal Ablation Therapy

Radiofrequency
Endovenous radiofrequency ablation of the GSV is another minimally invasive alternative to vein stripping and ligation. This method damages the intimal wall of the vessel by delivering high-frequency radiowaves via a specially designed catheter. Heat produced by these radiowaves collapses the vein, causing the vessel to close upon slow withdrawal of the catheter. The VNUS Closure® System (VNUS Medical Technologies, Inc., San Jose, CA) is a radiofrequency device that is approved by the US Food and Drug Administration (FDA) for the endovascular coagulation of blood vessels in individuals with superficial vein reflux.

Laser
Endovenous laser ablation of the saphenous veins is a minimally invasive alternative to vein stripping and ligation. Under ultrasound guidance, a bare-tipped laser is introduced into the GSV, activated, and slowly withdrawn, causing the vessel to collapse. The Diomed 810-nm Surgical Laser and Endovenous Laser Therapy (EVLT®) Procedure Kit (Diomed, Inc., Andover, MA) are approved by the FDA for the endovascular coagulation of blood vessels in individuals with superficial vein reflux.

Endovenous Mechanochemical Ablation (MOCA)

MOCA; e.g., Clarivein™ [Vascular Insights, Madison, CT]) is a minimally invasive treatment for varicose veins, combining mechanical and chemical modalities. The procedure involves the use of a special percutaneous infusion catheter, which contains a rotating wire, providing endovenous mechanical destruction. Simultaneously, an FDA-approved sclerosing agent (e.g., sodium tetradecyl sulfate) is administered to enhance occlusion of the vein.

Four randomized controlled trials (RCTs) with over 100 individuals each (range, 132–213) have been identified that compared MOCA to thermal ablation. The earliest two publications (Bootun et al. [2016]; Lane et al. [2017]) reported on early results from an RCT of 170 individuals that compared ClariVein with radiofrequency ablation (RFA). Maximum visual analog score (VAS) pain scores (of 100) during the procedure were significantly lower in the MOCA group (median, 15 mm) than in the RFA group (median, 34 mm; P=0.003). Average VAS pain scores during the procedure were also modestly lower in the MOCA group (median, 10 mm) than in the RFA group (median, 19.5 mm; P=0.003). Occlusion rates, clinical severity scores, disease-specific quality of life (QOL), and generic QOL scores were similar between the groups at 1 and 6 months. Only 71% of individuals were available for follow-up at 6 months, limiting the evaluation of closure rates during short term follow-up period.

Vahaaho et al. (2019) reported an RCT that compared MOCA with endovenous thermal ablation (endovenous laser ablation or RFA). Liquid sclerosant at a concentration of 1.5% was used. Of 132 individuals enrolled, seven were later excluded and 117 (88.6%) attended the 1-year follow-up evaluation. Occlusion of the GSV was observed in 45 of 55 (82%) of the MOCA group compared to 100% of the endovenous laser ablation and RFA groups (P=0.002). Another randomized trial by Lam et al. (2016) reported interim results of a dose-finding study, finding greater closure with the use of polidocanol 2% or 3% (liquid) than with polidocanol 1%. Therefore, it is uncertain whether the concentration of sclerosant in the study by Vahaaho et al. (2019) was optimal.

Three percent polidocanol was tested in the MARADONA (Mechanochemical endovenous Ablation to RADiOfrequeNcy Ablation) noninferiority trial reported by Holewijn et al. (2019). Although the study was powered for 400 participants, only 213 individuals were randomly assigned before reimbursement for the procedure was suspended. Pain scores in the 14 days after the procedure were slightly lower, but hyperpigmentation was higher. Anatomic failures were significantly greater in the MOCA group at 1 year and approached significance at 2 years—with the note that the study was underpowered for anatomic failures because of the early stoppage of the study. At 1 and 2 years, clinical and QOL outcomes were similar across the two groups.

A fourth RCT reported by Mohamed et al. (2020) is the ongoing LAMA (Randomized Clinical Trial Comparing Endovenous Laser Ablation and Mechanochemical Ablation [ClariVein] in the Management of Superficial Venous Insufficiency) trial. Individuals (n=150) were randomly assigned to MOCA with 1.5% sodium tetradecyl sulfate or to endovenous laser ablation. Anatomic success (occlusion) rates were lower in the MOCA group (77%) compared to the endovenous laser ablation group (91%) with no significant difference between the two treatments in intraprocedural pain scores. In contrast to the difference in anatomical occlusion rates, clinical severity and QOL scores were not significantly different between the groups at 1-year follow-up. Follow-up is continuing to evaluate the durability of the treatments.

Summary of Evidence for Endovenous Mechanochemical Ablation

MOCA is a combination of liquid sclerotherapy and mechanical abrasion of the lumen. The evidence on MOCA includes four RCTs that compared MOCA to thermal ablation with 6-month to 2-year results, and a prospective cohort with follow-up out to 5 years. Results to date have been mixed regarding a reduction in intraprocedural pain, which is a proposed benefit of MOCA compared to thermal ablation procedures. Occlusion rates at 6 months to 2 years in the RCTs indicate lower anatomic success rates compared to thermal ablation, but a difference in clinical outcomes at these early time points has not been observed. Experience with other endoluminal ablation procedures suggests that lower anatomic success in the short term is associated with recanalization and clinical recurrence between 2 to 5 years. The possibility of later clinical recurrence is supported by a prospective cohort study with 5-year follow-up following treatment with MOCA. However, there have been improvements in technique since the cohort study was begun, and clinical progression is frequently observed with venous disease. Because of these limitations, longer follow-up of the more recently conducted RCTs is needed to establish the efficacy and durability of this procedure compared with the criterion standard of thermal ablation.

Stab Phlebectomy

Stab phlebectomy is a technique of removing varicose veins through multiple small incisions. Stab phlebectomy may be performed in conjunction with stripping and ligation.

Transilluminated Powered Phlebectomy (TriVex System)

Transilluminated powered phlebectomy (the TriVex System, Smith+Nephew, Inc., Andover, MA) is a minimally invasive procedure in which an endoscopic illuminator is inserted into the vein to allow visualization of the varicose vein clusters. The veins are then ablated using a vein resector. During destruction of the veins, the debris is removed from the wound using suction.

Sclerotherapy

Sclerotherapy involves the destruction of the endothelium (or lining) of the targeted vessels by injection of a sclerosing solution. The accuracy of the injection, an adequate volume of injectant, and the concentration of the sclerosant determine the success of the treatment. Sclerotherapy can be performed in conjunction with surgical treatment of varicose veins of the lower extremities. The sclerotherapy agents currently available are classed by their actions in causing endothelial damage: osmotic or detergent agents. Osmotic agents achieve their effect by dehydrating endothelial cells through osmosis. Hypertonic saline and glycerin are two types of osmotic agents; however, glycerin is currently not commercially available in the United States. Sodium tetradecyl sulfate (Sotradecol®) and polidocanol (Asclera®) are detergent agents, which are surface-active agents that cause endothelial damage by interfering with cell membrane lipids. In review of available published literature, a systematic review of 17 RCTs of injection sclerotherapy for varicosities of varying size found no evidence to support use of one sclerosant over another in the short-term success of sclerotherapy.

In addition to the use of sclerotherapy in conjunction with surgical treatment, endovenous thermal ablation therapy (radiofrequency or laser) may be utilized solely for aesthetic or cosmetic purposes; such is the case for the treatment of telangiectasia (spider veins) without the presence of spontaneous and/or traumatic venous hemorrhage. Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiological function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiological function. For example, a product such as polidocanol (Asclera®) has potential to be used solely for cosmetic purposes because it was approved by the FDA as a sclerosing agent indicated to treat uncomplicated spider veins (varicose veins ≤1 mm in diameter) and uncomplicated reticular veins (varicose veins 1–3 mm in diameter); polidocanol (Asclera®) has not been studied in varicose veins larger than 3 mm.

Sclerotherapy using a liquid sclerosing agent previously has been the gold standard; however, foam sclerosing agents have emerged as a popular therapy option in the treatment of varicose veins, tributaries, and telangiectases. Foam sclerosants are produced by forcibly mixing a gas (e.g., air, carbon dioxide) with a liquid sclerosant (i.e., polidocanol, sodium tetradecyl sulfate), allowing for a larger surface area of exposure. The expanded volume of the foam compared with liquid agents has exhibited more surface contact, a more uniform vessel closure, and the need for smaller volumes of sclerosant. The rates of occlusion with the FDA-approved microfoam sclerotherapy are similar to those reported for endovenous laser ablation or stripping. Varithena™ (formerly known as Varisolve®, BTG PLC, London) is a sclerosant microfoam made with proprietary gas mix. Varithena received FDA approval in 2013, under a new drug application (NDA) for the treatment of incompetent GSVs, accessory saphenous veins, and visible varicosities of the GSV system above and below the knee.

A Cochrane review of 28 studies by de Ávila Oliveira et al. (2021) concluded that there is low-certainty evidence that sclerotherapy is effective and safe compared to placebo for treating cosmetic appearance, persistent symptoms, and QOL concerns related to varicose veins. Evidence was limited or lacking for comparisons of foam with liquid sclerotherapy or other substances, and between concentrations of foam. Sclerotherapy and phlebectomy are considered appropriate in the absence of reflux of the saphenous system (e.g., post- or adjunctive treatment to other procedures such as surgery).

A Cochrane review by Whing et al. (2021) compared interventions for GSV incompetence and included 24 RCTs (N=5135); the duration of follow-up for included trials ranged from 5 weeks to 8 years. Based on pooled data from four RCTs (n=954), ultrasound-guided foam sclerotherapy (UGFS) was inferior to ligation and stripping for technical success up to 5 years (odds ratio [OR], 0.32; 95% CI, 0.11–0.94; low-certainty evidence), and beyond 5 years based on three RCTs (n=525) (OR, 0.09; 95% CI–0.30; moderate-certainty evidence). There was no significant difference between treatments for recurrence up to 3 years based on three RCTs (n=822) and beyond 5 years based on three RCTs (n=639). Similarly, technical success was improved with endovenous laser ablation over UGFS up to 5 years based on data from three RCTs (n=588) (OR, 6.13; 95% CI, 0.98–38.27; low-certainty evidence), and beyond 5 years based on data from three RCTs (n=534) (OR, 6.47; 95% CI, 2.60–16.10; low-certainty evidence). There was no significant difference between endovenous laser ablation and UGFS for recurrence up to 3 years based on data from two RCTs (n=443), and at 5 years based on data from two RCTs (n=418).

Ultrasound-Guided Sclerotherapy

Ultrasound sclerotherapy utilizes duplex ultrasound to guide the injection of the sclerosing solution and to enhance the precision of saphenous vein sclerotherapy. This procedure may be referred to as echosclerotherapy or ultrasound-guided sclerotherapy. The goal of UGFS when treating varicose veins is to damage the endothelial surface of the vein to cause scarring and blockage of the treated vein. Under local anesthesia, the sclerosant foam is injected into the affected veins using ultrasound. The foam sclerosant causes an inflammatory reaction in the vein wall, causing vein blockage. Compression bandages are applied following the procedure.

Nesbitt et al. (2014), in a systematic review, compared endovenous thermal ablation (radiofrequency and laser) and foam sclerotherapy to ligation and stripping for GSV varices. The review included a total of 13 randomized studies consisting of a combined 3081 participants. Due to variations in reporting of results, the overall quality of the evidence was deemed to be moderate. The authors concluded that currently available clinical trial evidence suggests that UGFS, endovenous thermal ablation (radiofrequency or laser) therapy are at least as effective as surgery in the treatment of GSV veins.

Catheter-Directed Chemical Ablation with Balloon Isolation (KAVS)

Catheter-directed chemical ablation with balloon isolation (KAVS) is a type of catheter-assisted vein sclerotherapy, which involves a double lumen intravascular catheter with a balloon attached intended to temporarily block the blood flow to the sclerotherapy-treated vein. The evidence base has not developed since initially described in the literature. The evidence base to evaluate the safety and efficacy of KAVS sclerotherapy is limited, and remains insufficient to draw firm conclusions on the use of KAVS.

Cyanoacrylate Adhesive

Cyanoacrylate adhesive is a clear, free-flowing liquid that polymerizes in the vessel via an anionic mechanism (i.e., polymerizes into a solid material upon contact with body fluids or tissue). Under local anesthesia, the adhesive is gradually injected along the length of the vein in conjunction with ultrasound and manual compression. The acute coaptation halts blood flow through the vein until the implanted adhesive, typically delivered in measured doses, becomes fibrotically encapsulated and establishes chronic occlusion of the treated vein.

The VenaSeal® Closure System (Sapheon, a part of Medtronic), which seals the vein using a cyanoacrylate adhesive agent, received FDA approval in 2015 for the permanent closure of clinically significant venous reflux through endovascular embolization with coaptation. The technique of cyanoacrylate closure (CAC), which is one of the most common liquid embolic agents, uses a proprietary adhesive for the treatment of refluxing saphenous veins.

Gibson and Ferris (2017) reported results of the prospective WAVES study of cyanoacrylate closure for the treatment of GSVs, small saphenous veins, and/or accessory saphenous veins up to 20 mm in diameter (n=50). Compression stockings postprocedure were not utilized. Participants returned at 1 week and 1 month for follow-up. All treated veins (48 GSV, 14 accessory saphenous veins, and eight small saphenous veins) had complete closure by duplex ultrasound at 7 days and 1 month. Mean time to return to work and normal activities was 0.2 ± 1.1 and 2.4 ± 4.1 days, respectively. The revised venous clinical severity score was improved to 1.8 ± 1.4 (P<0.001) and Aberdeen Varicose Vein Questionnaire score to 8.9 ± 6.6 (P<0.001) at 1 month. Phlebitis in the treatment area or side branches occurred in 10 subjects (20%) and completely resolved in all but one subject (2%) by 1 month. The authors concluded that cyanoacrylate closure is safe and effective for the treatment of one or more incompetent saphenous or accessory saphenous veins; closure rates were high even in the absence of the use of compression stockings or side branch treatment. Time to return to work or normal activities was short and improvements in venous severity scores and QOL were, in the authors’ opinion, significant, comparing favorably with alternative treatment methods.

The VenaSeal pivotal study (VeClose), a multicenter noninferiority trial with 222 enrollees, compared VenaSeal with RFA for the treatment of venous reflux. The pivotal registration study for the VeClose study and follow-up through 36 months report that the primary endpoint (the proportion of individuals with complete closure of the target GSV at 3 months measured by ultrasound) was noninferior to RFA, with a 99% closure rate for VenaSeal compared with 96% for RFA. The secondary endpoint (intraoperative pain) was similar for both groups (2.2 on a 10-point scale for VenaSeal vs. 2.4 for RFA; P=0.11). Ecchymosis at day 3 was significantly lower in the cyanoacrylate group; 67.6% of individuals treated with cyanoacrylate had no ecchymosis compared with 48.2% of individuals following RFA (P<0.01). Scores on the AVVQ and Venous Clinical Severity Score improved to a similar extent in both groups. The mean time to return to work in a prospective cohort of 50 participants reported by Gibson and Ferris (2017) was 0.2 days.

For the CAC and RFA groups, the complete occlusion rates were 97.2% and 97.0%. Freedom from recanalization was also similar between the two groups (P=0.08). Twenty-four-month results were reported by Gibson et al. (2018), which included 171 participants (87 from CAC and 84 from RFA). Thirty-six-month results were reported by Morrison et al. (2019), with follow-up on 146 (66%) individuals (72 from CAC and 74 from RFA). Loss to follow-up was similar in the two groups. The complete closure rates for CAC and RFA were 94.4% and 91.9% (P=0.005 for noninferiority), respectively. Recanalization-free survival through 36 months was not statistically different for the two groups. No significant device- or procedure-related adverse events were reported for either group.

VariClose CAC was compared with RFA and endovenous laser ablation by Eroglu and Yasim (2018) in an RCT with 525 individuals. Periprocedural outcomes showed a shorter intervention time, less pain, and shorter return to work with CAC compared to endovenous thermal ablation. There was no significant difference in occlusion rates among the three treatments at 6, 12, and 24-month follow-up.

Alhewy et al. (2024) conducted an RCT at two centers in Egypt comparing VenaSeal CAC with RFA in 248 participants with venous reflux, with follow-up extending to 2 years postprocedure. The primary outcome was complete closure of the target GSV at the 3-month visit, although results for this outcome were not reported by the authors. The authors reported that at the 1-month follow-up, all veins treated with CAC remained occluded, while 154 of 158 (97%) veins treated with RFA remained occluded. At 24 months, 122 of 128 (95%) veins treated with CAC and 146 of 158 (93%) veins treated with RFA remained occluded. At month 24, there were six recanalizations in the CAC group and 12 in the RFA group, with recanalization-free survival in the CAC group found to be noninferior to that of the RFA group (95.3% vs. 92.4%, respectively; P<0.0001 for 10% noninferiority). The CAC group experienced fewer complications, with only two cases of paresthesia and 18 cases of bruises reported, whereas the RFA group encountered 18 cases of bruises, two cases of skin burns, and two cases of access site hematoma. Periprocedural outcomes showed a potentially shorter intervention time with CAC versus RFA.

Summary of Evidence for Cyanoacrylate Adhesive

Evidence assessing CAC for the treatment of varicose veins and venous insufficiency includes a multicenter noninferiority trial with follow-up through 36 months, two RCTs with follow-up through 24 months, and a prospective cohort with 30 months of follow-up. The short-term efficacy of VenaSeal CAC has been shown to be noninferior to RFA at up to 36 months of follow-up. At 24 and 36 months, the study had greater than 20% loss to follow-up, but loss to follow-up was similar in the two groups at the long-term follow-up and is not expected to influence comparative results. Another RCT (N=248) comparing VenaSeal CAC with RFA found similar proportions of vein closures at 24 months with both treatments (100% and 95%, respectively; P value not reported), with potentially shorter procedure duration with CAC versus RFA (25 to 54 minutes and 40 to 70 minutes, respectively; P value not reported). An RCT (N=525) with an active CAC ingredient (N-butyl cyanoacrylate) that is currently available outside of the United States found no significant differences in vein closure between CAC and thermal ablation controls at 24 months of follow-up. The CAC procedure and return to work were shorter and pain scores were lower compared to thermal ablation; the subjective pain scores may have been influenced by differing expectations in this study. A prospective cohort reported high closure rates at 30 months. Overall, results indicate that outcomes from CAC are at least as good as thermal ablation techniques, the current standard of care.

Cryoablation

Cryoablation uses extreme cold to cause injury to the vessel, causing retraction and subsequent fibrotic occlusion to the vein. For individuals who have varicose veins/venous insufficiency and saphenous vein reflux who receive cryoablation, the evidence includes RCTs and multicenter series. Relevant outcomes are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity. Results from a recent RCT of cryoablation have indicated that this therapy is inferior to conventional stripping. Studies showing a benefit on health outcomes are needed. The evidence is insufficient to determine the effects of the technology on health outcomes.

PERFORATOR VEINS AND TREATMENT OF INCOMPETENCE

Perforator veins are an irregular group of veins that grow as tributaries of the GSVs and connect the superficial venous system to the deep venous system. They permit the unidirectional flow of blood from the superficial to the deep venous system through a set of one-way valves. These valves can become incompetent and have been linked to chronic venous insufficiency (CVI), which is characterized by induration and inflammation of the skin and subcutaneous tissues, as well as microvascular stasis that ultimately leads to tissue destruction and chronic ulceration.

Surgical treatment of incompetent perforator veins as a treatment for CVI can be performed by an open approach, endoscopic approach, or by endovenous radiofrequency or laser ablation. The original treatment approach was the Linton procedure, an open approach, which involved a long medial calf incision to expose posterior, medial, and paramedial perforators. This procedure was associated with the healing of ulcers but, over time, has been largely abandoned due to incidences of wound complications. As a result, the Linton procedure's approach was modified to a series of perpendicular skin flaps instead of a longitudinal skin flap to provide access to incompetent perforator veins in the lower part of the leg. This modified Linton procedure may be used for the closure of incompetent perforator veins that cannot be accessed by less invasive procedures. SEPS is a minimally invasive procedure whereby duplex ultrasound guidance is used, and small incisions are made in the skin. Using endoscopic techniques, the perforator veins are clipped or divided by endoscopic scissors.

Endovenous thermal (radiofrequency and laser) ablation therapy is utilized in a similar fashion as with incompetent saphenous veins, as described above.

Giannopoulos et al. (2022) performed a systematic review of percutaneous treatments for pathologic perforating veins. Thirty-five studies met the inclusion criteria (five double-arm studies and 28 single-arm studies). Endovenous laser ablation (with or without microphlebectomy and/or sclerotherapy) was successful within the first 2 weeks after the procedure in 95% of individuals. Success rates for RFA (with or without microphlebectomy) were 91% (95% CI, 75–99). Ultrasound-guided sclerotherapy had a success rate of 70% after multiple sessions (95% CI, 53–84). After 12 months of follow-up, occlusion rates were 89%, 77%, and 83% in the three groups, respectively. Limitations of the review include heterogeneity of the interventions in the included studies, including adjuvant therapy that could be provided at the investigator's discretion.

Ho et al. (2022) published a systematic review to compare interventions for incompetent perforator veins, including open ligation, SEPS, endovascular laser ablation, ultrasound-guided sclerotherapy, and RFA. Eighty-one studies (N=7010) were identified, and the overall quality of evidence was low to intermediate. Results demonstrated that in the short term (≤1 year), efficacy rates for wound healing were 99.9% for ultrasound-guided sclerotherapy, 72.2% for open ligation, and 96.0% for SEPS. For short-term freedom from wound recurrence, the pooled estimate for SEPS was 91.0%; wound recurrence rates were not reported for other interventions.

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Coding

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

36465, 36466, 36468, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785

THE FOLLOWING CODE IS USED TO REPRESENT TRANSILLUMINATED POWERED PHLEBECTOMY (e.g., TriVex system):

37799

THE FOLLOWING CODE IS USED TO REPRESENT STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY, FEWER THAN 10 INCISIONS:

37799

EXPERIMENTAL/INVESTIGATIONAL

0524T, 36473, 36474

THE FOLLOWING CODE IS USED TO REPRESENT ENDOVENOUS CRYOABLATION OF ANY VEIN:

37799

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

MEDICALLY NECESSARY

I80.00 Phlebitis and thrombophlebitis of superficial vessels of unspecified lower extremity

I80.01 Phlebitis and thrombophlebitis of superficial vessels of right lower extremity

I80.02 Phlebitis and thrombophlebitis of superficial vessels of left lower extremity

I80.03 Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateral

I80.3 Phlebitis and thrombophlebitis of lower extremities, unspecified

I83.001 Varicose veins of unspecified lower extremity with ulcer of thigh

I83.002 Varicose veins of unspecified lower extremity with ulcer of calf

I83.003 Varicose veins of unspecified lower extremity with ulcer of ankle

I83.004 Varicose veins of unspecified lower extremity with ulcer of heel and midfoot

I83.005 Varicose veins of unspecified lower extremity with ulcer other part of foot

I83.008 Varicose veins of unspecified lower extremity with ulcer other part of lower leg

I83.009 Varicose veins of unspecified lower extremity with ulcer of unspecified site

I83.011 Varicose veins of right lower extremity with ulcer of thigh

I83.012 Varicose veins of right lower extremity with ulcer of calf

I83.013 Varicose veins of right lower extremity with ulcer of ankle

I83.014 Varicose veins of right lower extremity with ulcer of heel and midfoot

I83.015 Varicose veins of right lower extremity with ulcer other part of foot

I83.018 Varicose veins of right lower extremity with ulcer other part of lower leg

I83.019 Varicose veins of right lower extremity with ulcer of unspecified site

I83.021 Varicose veins of left lower extremity with ulcer of thigh

I83.022 Varicose veins of left lower extremity with ulcer of calf

I83.023 Varicose veins of left lower extremity with ulcer of ankle

I83.024 Varicose veins of left lower extremity with ulcer of heel and midfoot

I83.025 Varicose veins of left lower extremity with ulcer other part of foot

I83.028 Varicose veins of left lower extremity with ulcer other part of lower leg

I83.029 Varicose veins of left lower extremity with ulcer of unspecified site

I83.10 Varicose veins of unspecified lower extremity with inflammation

I83.11 Varicose veins of right lower extremity with inflammation

I83.12 Varicose veins of left lower extremity with inflammation

I83.201 Varicose veins of unspecified lower extremity with both ulcer of thigh and inflammation

I83.202 Varicose veins of unspecified lower extremity with both ulcer of calf and inflammation

I83.203 Varicose veins of unspecified lower extremity with both ulcer of ankle and inflammation

I83.204 Varicose veins of unspecified lower extremity with both ulcer of heel and midfoot and inflammation

I83.205 Varicose veins of unspecified lower extremity with both ulcer other part of foot and inflammation

I83.208 Varicose veins of unspecified lower extremity with both ulcer of other part of lower extremity and inflammation

I83.209 Varicose veins of unspecified lower extremity with both ulcer of unspecified site and inflammation

I83.211 Varicose veins of right lower extremity with both ulcer of thigh and inflammation

I83.212 Varicose veins of right lower extremity with both ulcer of calf and inflammation

I83.213 Varicose veins of right lower extremity with both ulcer of ankle and inflammation

I83.214 Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation

I83.215 Varicose veins of right lower extremity with both ulcer other part of foot and inflammation

I83.218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation

I83.219 Varicose veins of right lower extremity with both ulcer of unspecified site and inflammation

I83.221 Varicose veins of left lower extremity with both ulcer of thigh and inflammation

I83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammation

I83.223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation

I83.224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation

I83.225 Varicose veins of left lower extremity with both ulcer other part of foot and inflammation

I83.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation

I83.229 Varicose veins of left lower extremity with both ulcer of unspecified site and inflammation

I80.241 Phlebitis and thrombophlebitis of right peroneal vein

I80.242 Phlebitis and thrombophlebitis of left peroneal vein

I80.243 Phlebitis and thrombophlebitis of peroneal vein, bilateral

I80.249 Phlebitis and thrombophlebitis of unspecified peroneal vein

I80.251 Phlebitis and thrombophlebitis of right calf muscular vein

I80.252 Phlebitis and thrombophlebitis of left calf muscular vein

I80.253 Phlebitis and thrombophlebitis of calf muscular vein, bilateral

I80.259 Phlebitis and thrombophlebitis of unspecified calf muscular vein

I83.811 Varicose veins of right lower extremity with pain

I83.812 Varicose veins of left lower extremity with pain

I83.813 Varicose veins of bilateral lower extremities with pain

I83.819 Varicose veins of unspecified lower extremity with pain

I83.891 Varicose veins of right lower extremity with other complications

I83.892 Varicose veins of left lower extremity with other complications

I83.893 Varicose veins of bilateral lower extremities with other complications

I83.899 Varicose veins of unspecified lower extremity with other complications

I87.2 Venous insufficiency (chronic) (peripheral)

PROCEDURE CODE (CPT 36468) IS CONSIDERED MEDICALLY NECESSARY FOR THE FOLLOWING INDICATIONS:

D69.8 Other specified hemorrhagic conditions

I78.0 Hereditary hemorrhagic telangiectasia

R58 Hemorrhage, not elsewhere classified

HCPCS Level II Code Number(s)

MEDICALLY NECESSARY

S2202 Echosclerotherapy

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

The following CPT codes should be used to report sclerotherapy for treatment of non-truncal varicose veins and injection of physician compounded foam in any vein: 36470, 36471. CPT codes 36465 and 36466 should not be used for treatment of symptomatic varicose tributaries, or to report injection of physician compounded foam. CPT codes 36465, 35466 are used to report non-compounded foam for the treatment of truncal veins only.

Cross Reference

Policy History

Revisions From 11.02.01u:

07/28/2025

This version of the policy will become effective 07/28/2025.

The intent of this policy remains unchanged; however, language was added in the Policy statement and Coding Table to clarify TIPP (adding "Trivex System").

The following NOC CPT was added to represent endovenous cryoablation: 37799 (Experimental/Investigational).

Revisions From 11.02.01t:

01/13/2025

This version of the policy will become effective 01/13/2025.

A medically necessary coverage statement was added for foam sclerotherapy and cyanoacrylate adhesive.

Experimental/investigational statements were added for catheter-assisted vein sclerotherapy with ballon isolation, sclerotherapy of perforator veins and sclerotherapy techniques, other than microfoam of saphenous veins.

The coverage position for the following code was revised from Cosmetic to Medically Necessary: 36468.

The coverage position for the following codes was revised from Experimental/Investigational to Medically Necessary: 36482, 36483

The coverage position for the following code was revised from Not Medically Necessary to Medically Necessary: S2202 Echosclerotherapy.

The following NOC code was added to the policy to represent stab phlebectomy fewer than 10 incisions: 37799 (Medically Necessary).

A coding/billing requirement to provide direction on correct coding for sclerotherapy treatment of tributaries and physician compounded foam was added.

Revisions From 11.02.01s:

10/01/2019

This policy has been identified for the ICD-10 code update, effective 10/01/2019.

The following ICD-10 codes has been added to this policy:

I80.241 Phlebitis and thrombophlebitis of right peroneal vein

I80.242 Phlebitis and thrombophlebitis of left peroneal vein

I80.243 Phlebitis and thrombophlebitis of peroneal vein, bilateral

I80.249 Phlebitis and thrombophlebitis of unspecified peroneal vein

I80.251 Phlebitis and thrombophlebitis of right calf muscular vein

I80.252 Phlebitis and thrombophlebitis of left calf muscular vein

I80.253 Phlebitis and thrombophlebitis of calf muscular vein, bilateral

I80.259 Phlebitis and thrombophlebitis of unspecified calf muscular vein

Revisions From 11.02.01r:

04/01/2019

This version of the policy will become effective 04/01/2019. The intent of this policy remains unchanged, but the policy was updated to further clarify criteria and introduce provider accreditation requirements to the policy.

Revisions From 11.02.01q:

01/01/2019

Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.

This policy has been identified for the CPT code update, effective 01/01/2019.

The following CPT code has been added to this policy:

0524T Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or percutaneous, including all vascular access, catheter manipulation, diagnostic imaging, imaging guidance and monitoring

Revisions From 11.02.01p:

03/27/2018

This version of the policy will become effective 03/27/2018.

The following criteria have been added to this policy:

Qualifications have been added to the symptomatic medically necessary indications

The following criteria have been revised in this policy:

Removal of sclerotherapy treatment for symptomatic greater or lesser saphenous varicose veins/chronic venous insufficiency.

The coverage position has been revised from medically necessary to experimental/investigational for endovenous mechanochemical ablation of any vein.

Revisions From 11.02.01o:

01/01/2018

This policy has been identified for the CPT code update, effective 01/01/2018.

The following CPT codes have been added to this policy:

36465 (Medically Necessary), 36466 (Medically Necessary), 36482 (Experimental/Investigational), 36483 (Experimental/Investigational)

The following CPT code narratives have been revised in this policy:

36468, 36470, 36471

Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date:

7/28/2025

Version Issued Date:

7/28/2025

Version Reissued Date: