129 Form

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Prior Authorization Request Form for Treatment of Varicose Veins/Venous Insufficiency #129

Medical Policy #238 Treatment of Varicose Veins/Venous Insufficiency

Please use this form to assist in identifying members who meet Blue Cross Blue Shield of Massachusetts’ (BCBSMA’s) medical necessity criteria for Treatment of Varicose Veins/Venous Insufficiency. For members who do not meet the criteria, submit a letter of medical necessity with a request for Clinical Exception (Individual Consideration).

CLINICAL DOCUMENTATION Copies of clinical documentation that supports the medical necessity criteria for Treatment of Varicose Veins/Venous Insufficiency must be submitted with this form. If the patient does not meet all the criteria listed below, please submit a letter of medical necessity explaining why an exception is justified.

For in-state providers: Please complete the Prior Authorization Request Form for Treatment of Varicose Veins/Venous Insufficiency (129) using Authorization Manager, the PA form must be included as an attachment with the request if the electronically fillable form in Authorization Manager is not used.

Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.

To ensure the request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources • Refer to our Authorization Manager page for tips, guides, and video demonstrations.

When Authorization Manager is unavailable, the completed form may also be faxed to:
Medical and Surgical: 1-888-282-0780; Medicare Advantage: 1-800-447-2994.

For out of network providers: Requests should still be faxed to 888-973-0726.

Patient Information Patient Name:

Today’s Date: BCBSMA ID#:

First Date of Treatment: Date of Birth:

Place of Service: Outpatient  Inpatient 

Physician Information Facility Information Name:

Name:
NPI#:

NPI#:

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Address:

Address: Phone #: Is voicemail confidential at this number  YES  NO Phone #: Is voicemail confidential at this number  YES  NO Fax#: Is Fax confidential at this number  YES  NO Fax#: Is Fax confidential at this number  YES  NO

Please enter the relevant diagnosis code(s) below: Code Description

Please enter requested procedure code(s) below along with the veins to be treated, laterality, and units: Code Vein(s) to be treated Left / Right Units

SAPHENOUS VEINS Great or Small Saphenous Veins Treatment of the great or small saphenous veins by surgery (ligation and stripping), endovenous thermal ablation (radiofrequency or laser), microfoam sclerotherapy or cyanoacrylate adhesive may be considered MEDICALLY NECESSARY for symptomatic varicose veins/venous insufficiency when the following criteria have been met:

Please check off that the patient meets ALL the following criteria: • There is demonstrated saphenous reflux and CEAP [Clinical, Etiology, Anatomy, Pathophysiology] class C2 or greater, AND  • There is documentation of 1 or more of the following indications:  Ulceration secondary to venous stasis  Recurrent superficial thrombophlebitis  Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity  Persistent pain, swelling, itching, burning, or other symptoms are associated with saphenous reflux

                                            AND

Symptoms significantly interfere with activities of daily living

                                            AND

A failure after the use of medical grade compression stockings (medical grade at least 20-30mmHg pressure)

ACCESSORY SAPHENOUS VEINS Treatment of accessory saphenous veins by surgery (ligation and stripping), endovenous radiofrequency or laser ablation, microfoam sclerotherapy or cyanoacrylate adhesive may be considered MEDICALLY NECESSARY for symptomatic varicose veins/venous insufficiency when the following criteria have been met:

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Please check off that the patient meets ALL the following criteria: • Incompetence of the accessory saphenous vein is isolated, AND

 • There is demonstrated accessory saphenous reflux, AND

 • There is documentation of 1 or more of the following indications:  Ulceration secondary to venous stasis  Recurrent superficial thrombophlebitis  Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity
 Persistent pain, swelling, itching, burning, or other symptoms are associated with saphenous reflux

                                             AND

Symptoms significantly interfere with activities of daily living

                                             AND

A failure after use of medical grade compression stockings (medical grade at least 20-30mmHg pressure)

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

SYMPTOMATIC VARICOSE TRIBUTARIES The following treatments are considered MEDICALLY NECESSARY as a component of the treatment of symptomatic varicose tributaries when performed either at the same time or following prior treatment (surgical, radiofrequency, or laser) of the saphenous veins (none of these techniques has been shown to be superior to another): • Stab avulsion • Hook phlebectomy • Sclerotherapy • Transilluminated powered phlebectomy.

PERFORATOR VEINS Surgical ligation (including subfascial endoscopic perforator surgery) or endovenous radiofrequency or laser ablation of incompetent perforator veins may be considered MEDICALLY NECESSARY as a treatment of leg ulcers associated with chronic venous insufficiency when the following conditions have been met:

Please check off that the patient meets ALL the following criteria: • There is demonstrated perforator reflux, AND

 • The superficial saphenous veins (great, small or accessory saphenous and symptomatic varicose tributaries) have been previously eliminated, AND

 • Ulcers have not resolved following combined superficial vein treatment and compression therapy for at least 3 months, AND

 • The venous insufficiency is not secondary to deep venous thromboembolism

