UM 067 Policy Update 063020 2 Form

June 30, 2020

Re: Alliance Utilization Management (UM) Policy Update on Varicose Vein Ablation Dear Alliance Provider Partner,
Alameda Alliance for Health (Alliance) values our dedicated provider partner community. We are committed to continuously improving our provider and member customer satisfaction. We have an important update that we would like to share with you.
Effective, Saturday, August 1, 2020, only licensed MDs or DOs who have active board certification in specific specialties can render varicose vein ablation procedures, as outlined in our policy and procedure UM-067 Treatment of Varicose Veins (lower extremities).
Surgical Treatment of Varicose Veins will be limited to the following board certified specialties:  Vascular Surgery  Interventional Radiology (IR)  Dermatology  Cardiology  General Surgery We have included a copy of this policy and procedure for your reference. If you have any questions about this policy update, please call the Alliance Utilization Management Department at 1.510.747.4540 ext. 5, Monday through Friday, 8 am – 5 pm.

Sincerely,

Steve O’Brien, MD Chief Medical Officer
Alameda Alliance for Health

Enclosure:
UM-067 Treatment of Varicose Veins (lower extremities)

UM-067 Treatment of Varicose Veins (lower extremities) Page 1 of 3

POLICY AND PROCEDURE

Policy Number UM-067
Policy Name Treatment of Varicose Veins (lower extremities) Department Name Utilization Management Department Officer Chief Medical Officer Policy Owner Utilization Management Medical Director Line(s) of Business Medi-Cal, GroupCare Effective Date 5/21/2020 Approval/Revision Date 5/21/2020

POLICY STATEMENT

Alameda Alliance for Health (Alliance) covers medically necessary treatment for members with varicose veins when conservative treatment has been unsuccessful in resolving symptoms.
Various procedures in the treatment of varicose veins will be reviewed using MCG® guidelines.

PROCEDURE

1. Treatment of Varicose Veins (lower extremities) will be reviewed for medical necessity using MCG® guidelines.
2. Varicose vein ablation procedures can only be rendered by licensed MDs or DOs that have active board certification in the below specialties.
3. Surgical treatment of varicose veins will be limited to the following board certified specialties: a. Vascular surgery b. Interventional radiology [IR] c. Dermatology d. Cardiology e. General Surgery
4. Limitations: a. Cosmetic and Not Medically Necessary Treatment using sclerotherapy or various laser treatments of the telangiectatic dermal veins (for example, reticular, capillary, venule), which may be described as "spider veins" or "broken blood vessels" is considered cosmetic and not medically necessary.

UM-067 Treatment of Varicose Veins (lower extremities) Page 2 of 3

DEFINITIONS / ACRONYMS

Anti-embolism hose (also called elastic stockings or compression stockings): A type of stocking worn to prevent the formation of blood clots in the legs (thromboses); assisting in the return flow of the blood to the heart, and prevention of pooling in the veins; there are three support grades of prescription hose; mild to severe support (15-20, 20-30, 30-40 mmHg) which are generally used to assist with a medical condition and light support (8-15 mmHg) that may be used as a preventive measure.

Catheter ablation: A technique involving the application of either radiofrequency or laser energy through an endovenous catheter for the purpose of ablating varicose vein tissue of the GSV or SSV; this does not include the “closure” or ablation of a vein using the injection of a sclerosing agent through a hollow catheter.

Cosmetic: procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those that are primarily intended to preserve or improve appearance.

Saphenofemoral reflux: A backflow of blood in the veins causing varicose vein symptoms and bulging.

Saphenous vein: A vein that serves as the principal blood vessel returning blood from the surface of the leg back to the trunk.

Sclerotherapy: A treatment for varicose veins in which a chemical is injected into the vein causing the vein to shrink and close.

Varicose vein or varicosity: Veins that are abnormally swollen or enlarged due to weakening in the vein's wall. Measured in an upright position they are 3 mm in diameter or greater.

AFFECTED DEPARTMENTS/PARTIES

 Utilization Management  Provider Relations  Quality Improvement

RELATED POLICIES AND PROCEDURES

 UM-001 Utilization Management

RELATED WORKFLOW DOCUMENTS OR OTHER ATTACHMENTS

None

REVISION HISTORY

 UM-064 11/15/2018; retired 11/21/2019

UM-067 Treatment of Varicose Veins (lower extremities) Page 3 of 3  UM-067 eff. 05/21/2020

REFERENCES

1. Medi-Cal Part 2 Provider Manual: Medical Services for General Medicine: Surgery Cardiovascular System: Medi-Cal Update: Criteria for Surgical Treatment of Varicose Veins 4/1/2013

2. Milliman Clinical Guidelines (MCG) 23rd Edition: a. Saphenous Vein Ablation, radiofrequency [MCG ACG: A-0174 (AC)] 23rd Edition i. CPT code: 36475 ii. CPT code: 36476

   b. Saphenous Vein Ablation, Laser [ACG: A-0425 (AC)] 23rd Edition i. CPT code: 36478 ii. CPT code: 36479

   c. Sclerotherapy, Leg Veins [MCG: A-0170 Sclerotherapy, Leg Veins (AC)] 23rd Edition] i. CPT code: 36470 ii. CPT code: 36471

   d. Stab Phlebectomy [MCG: Stab Phlebectomy ACG: A-735 (AC) 23rd Edition i. CPT code: 37765 ii. CPT code: 37766

   MONITORING

3. Annual audits based on CPT codes submitted