Prior authorization request form Form

Varicose Vein Treatment Proprietary information of EmblemHealth. © 2026 EmblemHealth & Affiliates POLICY NUMBER LAST REVIEW MG.MM.SU.05rC January 23, 2026

Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the member meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request preauthorization or post-payment review. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. This clinical policy is not intended to pre-empt the judgment of the reviewing medical director or dictate to health care providers how to practice medicine. Health care providers are expected to exercise their medical judgment in rendering appropriate care. Health care providers are expected to exercise their medical judgment in rendering appropriate care.
EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary.
If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. Identification of selected brand names of devices, tests and procedures in a medical coverage policy is for reference only and is not an endorsement of any one device, test or procedure over another. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication.
EmblemHealth may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. EmblemHealth Services Company, LLC, has adopted this policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC, and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Definitions Venous insufficiency is a condition caused by venous hypertension, especially by ambulating. Normally, one-way valves help to maintain blood flow toward the heart against the force of gravity; however, weakened valves do not close properly, thus permitting backward blood flow, a condition referred to as reflux. Veins with incompetent valves become elongated, rope-like, bulged and thickened. These vessels are known as varicose veins and are a direct result of increased pressure secondary to reflux. Greater saphenous vein (thigh vein) reflux, which leads to pooling in the visible varicose vein, is a common cause of varicose veins in the legs.
Treatment therapies include conservative therapies (i.e., compression stockings, pain medications, leg elevation and local heat applications) as well as surgical treatments directed toward correcting the reflux.1

1 Varicose vein surgery or sclerotherapy during pregnancy is not usually appropriate because dilatation of veins in the legs is physiologic and will revert to normal after delivery, at which time a more accurate appraisal can be made.

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Table 1 – Allowable Procedures
Cyanoacrylate embolization (CAE) ablation (aka cyanoacrylate superglue, n-butyl- cyanoacrylate) (e.g., VariClose Vein Sealing System, VenaSeal Closure System) Minimally invasive, non-tumescent, non-thermal and non-sclerosant procedure that uses a medical adhesive to close the diseased vein in patients with symptomatic venous reflux.
Endovenous chemical ablation (EVCA) (sclerotherapy) A process by which an irritating foam or liquid chemical is directly injected into the affected veins causing them to scar.
Sclerotherapy of spider veins (0–1 mm diameter) and small varicosities (< 4 mm) are generally considered cosmetic in nature.
Sclerotherapy of larger veins may be medically necessary as long as concomitant saphenous insufficiency, if present, has been treated. Microfoam Sclerotherapy (Varithena®) Percutaneous endovenous ablation using manufactured polidocanol microfoam (Varithena®) is injected into veins using ultrasound, displacing blood from the vein and destroying the endothelial lining, which is replaced by scar tissue. Treatment of spider veins (0–1 mm diameter) and small varicosities (< 4 mm) are generally considered cosmetic in nature. Microfoam endovenous ablation (Varithena®) is indicated for the treatment of incompetent great saphenous veins, accessory saphenous veins, and visible varicosities of the great saphenous vein (GSV) system above and below the knee. In clinical trials, veins up to 25.9mm were treated. Endovenous laser ablation of the saphenous vein (ELAS) A minimally invasive method by which the affected vein (usually the great saphenous vein of the thigh) is destroyed using laser energy delivered via a laser fiber inserted into the vein. ELAS is an alternative to saphenous vein stripping and is indicated when there is duplex-proven saphenous reflux unresponsive to conservative therapy. Endovenous mechanochemical ablation (MOCA) (ClariVein Infusion Catheter) (See Limitations/Exclusions) Non-thermal non-tumescent ablation technique, which incorporates the use of a flexible, steerable infusion catheter with a 360° rotatable dispersion wire. The wire tip causes minimal mechanical damage to the endothelium, inducing vasospasm, and the rotating tip evenly distributes a sclerosing agent to the targeted treatment area. After treatment, sealing of the vein is confirmed ultrasonically. Sclerosis of the vein activates the clotting system, resulting in formation of a thrombus and occlusion of the vessel. Covered for Medicaid and Medicare members only Phlebectomy (surgical removal of non- truncal varicose veins) Described by many terms, including ambulatory phlebectomy, Muller’s Method, stab phlebectomy, and simply phlebectomy.
These are different terms, but they refer to the same essential procedure. Radiofrequency ablation (RFA) (Endoluminal radiofrequency thermal heating or radiofrequency endovenous occlusion, e.g., VNUS Closure®)
RFA has been used with or without ligation and division for treatment of incompetence of the saphenofemoral junction and varicosities of the great saphenous vein. A catheter delivers radiofrequency energy through a special electrode that causes controlled heating of the vessel wall, causing the vein to collapse and seal shut.
The VNUS Closure® procedure is a treatment alternative to surgical stripping of the great saphenous vein and is considered a form of RFA. RFA is indicated when there is duplex-proven saphenous reflux unresponsive to conservative therapy. Excision and ligation or avulsion of varicosities
One or more incisions are made over the varicose veins and the vein is excised and then either tied off (ligated) or, in the case of smaller varicosities, simply avulsed.

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Page 3 of 12 Guideline Members are eligible for coverage of any of the procedures in Table 1 when there is documented evidence of patency of the deep vein system and absence of occlusion or disease. (See Limitations/Exclusions) All procedures require the following documentation:

1. Progress-note documentation of failed conservative measures.
2. Venous Doppler or duplex ultrasound. (Pretreatment Doppler or duplex ultrasound examination must be performed for localization of sites of incompetence to allow individual treatment options and reduce the chance of reoccurrence.
3. Other documentation, as requested. At least one of the following criteria must be met:
4. Recurrent episodes of superficial thrombophlebitis and/or persistent symptoms interfering with activities of daily living for ≥ 90 days. Excision of varicosities is indicated for large symptomatic varicosities (> 4 mm diameter) unresponsive to conservative therapy (as long as concomitant saphenous insufficiency, if present, has been treated). Saphenous vein stripping and excision
   Incisions are made at the bottom (ankle end) and at the top (groin end) of the varicose vein. A thin wire-like instrument is inserted into the vein to strip the vein from the inside. Small incisions can also be made over the veins to remove them.
   In many cases, the saphenous vein may only be stripped from the groin to the knee or mid-calf instead of all the way to the ankle.
   Stripping of the saphenous veins is indicated when there is duplex-proven saphenous reflux unresponsive to conservative therapy. Subfascial endoscopic perforator vein surgery (SEPS) (See Limitations/Exclusions) SEPS is a minimally invasive procedure designed to interrupt incompetent perforator veins as a treatment of chronic venous insufficiency.
   Guided by Duplex ultrasound scanning, small incisions are made in the skin unaffected by the changes of severe chronic venous insufficiency. Using endoscopic techniques, the perforating veins are clipped or divided by endoscopic scissors.
   Covered for Medicaid and Medicare members only Transilluminated powered phlebectomy (TPP/TIPP) aka TriVex procedure (TriVex™)
   A minimally invasive type of ambulatory phlebectomy offered as an alternative to standard surgery for symptomatic varicosities of the leg.
   It is a 3-part procedure performed under general, regional, or local anesthesia, beginning with tumescent anesthesia to enhance visualization surrounding the varicose veins and to reduce operative discomfort.
   Tumescence anesthesia involves infusion of large amounts of saline mixed with lidocaine to reduce hemorrhage and epinephrine to delay absorption of lidocaine. Once adequate tumescent infiltration is achieved, the resector and illuminator are inserted and positioned underneath the skin through small (2-3 cm) incisions on either end of the varicosity. The tip of the resector follows the veins slowly to chop the veins and aspirate fragments. Once removal of the affected vein(s) is complete, a second stage tumescent anesthesia is employed to minimize blood loss, reduce bruising and hematoma formation and to decrease post-operative pain. The incisions are then closed using surgical tape or similar closures, and the leg is wrapped.

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Page 4 of 12 Symptoms may include aching, cramping, burning, itching and/or swelling during activity or prolonged after prolonged standing.

2. Occurrence of a single significant hemorrhage from a ruptured superficial varicosity, especially if a blood transfusion is required.
3. > 1 episode of minor hemorrhage from a ruptured superficial varicosity.
4. Intractable ulceration or infection secondary to venous stasis. Table 2 – Accessory Saphenous Veins Treatment of accessory saphenous veins by surgery (ligation and stripping), RFA, laser ablation or microfoam endovenous ablation (Varithena) may be considered medically necessary for symptomatic varicose veins/venous insufficiency when all the following criteria are met:
5. The great or small saphenous veins had been previously eliminated (at least 3 months).
6. There is demonstrated accessory saphenous reflux time of > 500 msec.

7. There is documentation of ≥ 1 of the following indications: a. Ulceration secondary to venous stasis that fails to respond to compressive therapy (no time limit). b. Recurrent superficial thrombophlebitis that fails to respond to compressive therapy. c. Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity. d. Persistent pain, swelling, itching, burning, or other symptoms are associated with saphenous reflux, and the symptoms significantly interfere with activities of daily living

   Notes

8. Initial authorization for sclerotherapy will be for 3 sclerotherapy treatments (CPT 36471) per leg as medically necessary. If further sclerotherapy treatments are requested, then updated clinical information (post-treatment) will be necessary for review.
9. Coverage of laser and RFA is indicated for small/great saphenous veins and anterior/posterior accessory saphenous veins to improve symptoms attributable to saphenofemoral or saphenopopliteal reflux when medical necessity criteria are met. (Maximum allowable vein diameters: ELAS — 20mm; RFA — 18mm)
10. There should be no aneurysm in the target segment.
11. Ultrasound guidance is not covered separately and is included in CPT codes 36465, 36466, 36475, 36476, 36478, and 36479.
12. One pre-operative Doppler ultrasound study or duplex scan will be covered.
13. One post-procedure Doppler ultrasound study or duplex scan will be covered.
    The use of ultrasound guidance procedures during varicose vein surgery should not be billed separately; these CPT codes are 76937, 76942, 76998, 76999, 93965, 93970, 93971 and S2202. (Note: Intraoperative ultrasound is covered for Medicare members only)
14. Selective catheter placement (CPT 36011) is included in procedures used to treat the varicose veins.
15. A procedure performed on the same vessel, above and below the knee, is considered the same procedure if done within a 3-month period.

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9. For ablations only a single date of service will be authorized per leg (i.e., all of the symptomatic axial veins in a single leg will be treated on one date of service). Only one primary ablation CPT code and one secondary ablation CPT code will be used to treat all of the axial veins in one leg.
10. Currently, a CPT code does not exist to describe the microfoam endovenous ablation procedure with ultrasound, therefore 37799 should be used with a crosswalk to 36475-36479, and 37765 with percutaneous endovenous ablation in box 19 or the electronic equivalent. Limitations and Exclusions
11. Endovenous mechanochemical ablation (MOCA) is considered investigational for Commercial members.
12. The following procedures are not considered medically necessary because they are regarded as cosmetic:
    a. Injection of reticular veins, telangiectasia or visible subcuticular veins < 4 mm in size (e.g., spider veins, angiomata and hemangiomata). (CPT codes: 36468 and 36469) b. Transdermal laser therapy and photodermal sclerosis.
13. Sclerotherapy for the great saphenous vein or varicose veins > 7 mm.
14. Treatment of incompetent perforator veins. (Coverage exception — presence of venous ulcer or history of venous ulcer to prevent recurrence)
15. All other procedure codes not listed in the Procedure Codes table.
16. Requests received for 2 procedures (occurring on the same day) will be reviewed in the same case, dependent on the LOMN, stating that the second procedure will be done within 14 days of the first procedure. Procedure Codes
    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 (eg, 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 (eg, great saphenous vein, accessory saphenous vein), same leg
    36468 Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk 36470 Injection of sclerosant; single incompetent vein (other than telangiectasia)
    36471 Injection of sclerosing solution sclerosant; multiple incompetent veins, (other than telangiectasia), same leg
    36473 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated (Only covered for Medicaid and Medicare members) 36474 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (Lisa separately in addition to code for primary procedure) (Only covered for Medicaid and Medicare members) 36475 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated 36476 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites

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Page 6 of 12 (List separately in addition to code for primary procedure)
36478 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated 36479 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)
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)
37500 Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS) (Only covered for Medicaid and Medicare members) 37700 Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions 37718 Ligation, division, and stripping, short saphenous vein 37722 Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below 37735 Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer and skin graft and/or interruption of communicating veins of lower leg, with excision of deep fascia 37760 Ligation of perforator veins, subfascial, radical (Linton type), including skin graft, when performed, open,1 leg
37761 Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg
37765 Stab phlebectomy of varicose veins, one extremity; 10-20 stab incisions 37766 Stab phlebectomy of varicose veins, one extremity; more than 20 incisions 37780 Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure) 37785 Ligation, division, and/or excision of varicose vein cluster(s), one leg 37799 Unlisted procedure, vascular surgery
76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation 93970 Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study 93971 Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study S2202 Echosclerotherapy (Commercial only)

ICD-10 Diagnoses 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

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Page 7 of 12 I80.10 Phlebitis and thrombophlebitis of unspecified femoral vein I80.11 Phlebitis and thrombophlebitis of right femoral vein I80.12 Phlebitis and thrombophlebitis of left femoral vein I80.13 Phlebitis and thrombophlebitis of femoral vein, bilateral I80.201 Phlebitis and thrombophlebitis of unspecified deep vessels of right lower extremity I80.202 Phlebitis and thrombophlebitis of unspecified deep vessels of left lower extremity I80.203 Phlebitis and thrombophlebitis of unspecified deep vessels of lower extremities, bilateral I80.209 Phlebitis and thrombophlebitis of unspecified deep vessels of unspecified lower extremity I80.221 Phlebitis and thrombophlebitis of right popliteal vein I80.222 Phlebitis and thrombophlebitis of left popliteal vein I80.223 Phlebitis and thrombophlebitis of popliteal vein, bilateral I80.229 Phlebitis and thrombophlebitis of unspecified popliteal vein I80.231 Phlebitis and thrombophlebitis of right tibial vein I80.232 Phlebitis and thrombophlebitis of left tibial vein I80.233 Phlebitis and thrombophlebitis of tibial vein, bilateral I80.239 Phlebitis and thrombophlebitis of unspecified tibial vein 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
I80.291 Phlebitis and thrombophlebitis of other deep vessels of right lower extremity I80.292 Phlebitis and thrombophlebitis of other deep vessels of left lower extremity I80.293 Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral I80.299 Phlebitis and thrombophlebitis of other deep vessels of unspecified lower extremity 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

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Page 8 of 12 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

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Page 9 of 12 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 I83.811 Varicose veins of right lower extremities with pain I83.812 Varicose veins of left lower extremities with pain I83.813 Varicose veins of bilateral lower extremities with pain I83.819 Varicose veins of unspecified lower extremities with pain I83.891 Varicose veins of right lower extremities with other complications I83.892 Varicose veins of left lower extremities with other complications I83.893 Varicose veins of bilateral lower extremities with other complications I83.899 Varicose veins of unspecified lower extremities with other complications I87.2 Venous insufficiency (chronic) (peripheral) I87.311 Chronic venous hypertension (idiopathic) with ulcer of right lower extremity I87.312 Chronic venous hypertension (idiopathic) with ulcer of left lower extremity I87.313 Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity I87.319 Chronic venous hypertension (idiopathic) with ulcer of unspecified lower extremity I87.321 Chronic venous hypertension (idiopathic) with inflammation of right lower extremity I87.322 Chronic venous hypertension (idiopathic) with inflammation of left lower extremity I87.323 Chronic venous hypertension (idiopathic) with inflammation of bilateral lower extremity I87.329 Chronic venous hypertension (idiopathic) with inflammation of unspecified lower extremity I87.331 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity I87.332 Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity I87.333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity I87.339 Chronic venous hypertension (idiopathic) with ulcer and inflammation of unspecified lower extremity I87.391 Chronic venous hypertension (idiopathic) with other complications of right lower extremity I87.392 Chronic venous hypertension (idiopathic) with other complications of left lower extremity I87.393 Chronic venous hypertension (idiopathic) with other complications of bilateral lower extremity I87.399 Chronic venous hypertension (idiopathic) with other complications of unspecified lower extremity References

1. American College of Phlebology. Treatment of Superficial Venous Disease of the Lower Leg. https://www.myavls.org/assets/pdf/VaricoseVeinGuidelines3.9.15.pdf. Accessed January 23, 2026.
2. Arumugasamy M, McGreal G, O'Connor A, Kelly C, Bouchier-Hayes D, Leahy A. The technique of transilluminated powered phlebectomy—a novel, minimally invasive system for varicose vein surgery. Eur J Endovasc Surg. February 2002; 23:180- 182.

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3. Baron HC, Saber AA, Wayne M. Endoscopic subfascial surgery for incompetent perforator veins in patients with active venous ulceration. Surg Endosc. January 2001;15:38-40.
4. Belcaro G, Cesarone MR, Di Renzo A, et al. Foam-sclerotherapy, surgery, sclerotherapy, and combined treatment for varicose veins: a 10-year, prospective, randomized, controlled trial (VEDICO trial). Angiology. 2003;54:307-315.
5. Bergan JJ. Advances in venous surgery: SEPS and phlebectomy for chronic venous insufficiency. Dermatol Surg. January 2002;28:26-28.
6. Bergan JJ. Varicose veins: hooks, clamps, and suction. Application of new techniques to enhance varicose vein surgery. Semin Vasc Surg. March 2002;15:21-26.
7. Bianchi C, Ballard JL, Abou-Zamzam AM, Teruya TH. Subfascial endoscopic perforator vein surgery combined with saphenous vein ablation: results and critical analysis. J Vasc Surg. July 2003;38:67-71.
8. Chandler JG, Pichot O, Sessa C, Schuller-Petrovic S, Osse FJ, Bergan JJ. Defining the role of extended saphenofemoral junction ligation: a prospective comparative study. J Vasc Surg. 2000;32:941-953.
9. Chen JZ, Alexiades-Armenakas MR, Bernstein LJ, Jacobson LG, Friedman PM, Geronemus RG. Two randomized, double- blind, placebo-controlled studies evaluating the S-Caine Peel for induction of local anesthesia before long-pulsed Nd:YAG laser therapy for leg veins. Dermatol Surg. 2003;29:1012-1018.
10. Ciostek P, Myrcha P, Noszczyk W. Ten years’ experience with subfascial endoscopic perforator vein surgery. Ann Vasc Surg. 2002;16:480-487.
11. Dauplaise TL, Weiss RA. Duplex-guided endovascular occlusion of refluxing saphenous veins. Journal of Vascular Technology. June 1, 2001;25:79-82.
12. Goldman MP, Amiry S. Closure of the greater saphenous vein with endoluminal radiofrequency thermal heating of the vein wall in combination with ambulatory phlebectomy: 50 patients with more than 6-month follow-up. Dermatol Surg. January 2002;28:29-31.
13. Kalra M, Gloviczki P. Subfascial endoscopic perforator vein surgery: who benefits? Semin Vasc Surg. March 2002;15:39-49.
14. Lupton JR, Alster TS, Romero P. Clinical comparison of sclerotherapy versus long-pulsed Nd:YAG laser treatment for lower extremity telangiectases. Dermatol Surg. 2002;28:694-697.
15. Manfrini S, Gasbarro V, Danielsson G, et al. Endovenous management of saphenous vein reflux. Endovenous Reflux Management Study Group. J Vasc Surg. 2000;32:330-342.
16. McDonagh B, Huntley DE, Rosenfeld R, et al. Efficacy of the comprehensive objective mapping, precise image-guided injection, anti-reflux positioning, and sequential sclerotherapy (COMPASS) technique in the management of greater saphenous varicosities with saphenofemoral incompetence [abstract and commentary]. Phlebology. 2002;17:19-29.
17. McDonagh B, Sorenson S, Gray C, et al. Clinical spectrum of recurrent postoperative varicose veins and efficacy of sclerotherapy management using the compass technique. Phlebology. 2003;18(4):173-186.
18. Min RJ, Zimmet SE, Isaacs MN, Forrestal MD. Endovenous laser treatment of the incompetent greater saphenous vein. J Vasc Interv Radiol. 2001;12:1167-1171.
19. National Government Services. Local Coverage Determination (LCD): Varicose Veins of the Lower Extremity. November
20. https://www.cms.gov/medicare-coverage- database/view/lcd.aspx?lcdid=33575&ver=43&CntrctrSelected=3001&Cntrctr=300&name=National+Government+Servic es%2c+Inc.+(National+Government+Services%2c+Inc.+(13202%2c+A+and+B+and+HHH+MAC%2c+J+- +K))&LCntrctr=3001&DocType=Active&bc=AgACAAQAgAAA&=. Accessed January 23, 2026.
21. National Institute for Health and Clinical Excellence. Radiofrequency Ablation of Varicose Veins. September 2003. https://www.nice.org.uk/guidance/IPG8. Accessed January 23, 2026.
22. National Institute for Health and Clinical Excellence. Transilluminated powered phlebectomy for varicose veins. January
23. https://www.nice.org.uk/guidance/IPG37. Accessed January 23, 2026.
24. Navarro L, Min RJ, Bone C. Endovenous laser: a new minimally invasive method of treatment for varicose veins— preliminary observations using an 810 nm diode laser. Dermatol Surg. February 2001;27:117-122.
25. O'Donnel Jr, T. The present status of surgery of the superficial venous system in the management of venous ulcer and the evidence for the role of perforator interruption. J Vasc Surg 2008; 48:1044-52.
26. Pichot O, Sessa C, Chandler JG, Nuta M, Perrin M. Role of duplex imaging in endovenous obliteration for primary venous insufficiency. J Endovasc Ther. 2000;7:451-459.
27. Raju S, Neglen P. Chronic venous insufficiency and varicose veins. N Engl J Med 2009; 360:22, 2319-27.

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26. Russell T, Logsdon AL. Subfascial endoscopic perforator surgery: a surgical approach to halting venous ulceration. J Wound Ostomy Continence Nurs. January 2002;29:33-36.
27. Sadick NS. Long-term results with a multiple synchronized-pulse 1064 nm Nd:YAG laser for the treatment of leg venulectasias and reticular veins. Dermatol Surg. 2001;27:365-369.
28. Scavee V, Theys S, Schoevaerdts JC. Transilluminated powered mini-phlebectomy: early clinical experience. Acta Chir Belg. Sept-Oct 2001;101:247-249.
29. Smith JJ, Brown L, Greenhalgh RM, Davies AH. Randomised trial of pre-operative colour duplex marking in primary varicose vein surgery: outcome is not improved. Eur J Vasc Endovasc Surg. 2002;23:336-343.
30. Sybrandy JE, Wittens CH. Initial experiences in endovenous treatment of saphenous vein reflux. J Vasc Surg. 2002;36:1207-
32. Tawes RL, Barron ML, Coello AA, Joyce DH, Kolvenbach R. Optimal therapy for advanced chronic venous insufficiency. J Vasc Surg. 2003;37:545-551.
33. Varithena® (polidocanol injectable foam [package insert]. West Conshohocken, PA: Biocompatables; 2013
34. Weiss RA, Weiss MA. Controlled radiofrequency endovenous occlusion using a unique radiofrequency catheter under duplex guidance to eliminate saphenous varicose vein reflux: a 2-year follow-up. Dermatol Surg. January 2002;28:38-42.
35. Weiss RA. Endovenous techniques for elimination of saphenous reflux: a valuable treatment modality. Dermatol Surg. 2001;27:902-905.
36. The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society of Vascular Surgery and the American Venous Forum. J Vasc Surg 53,16s.
37. AVF/SVS/ACP/SVM/IUP Guidelines for Compression After Invasive Treatment of Lower-Extremity Superficial Veins. 2019, clinical practice guidelines for the use of compression therapy after invasive treatment of superficial veins of the lower extremities were published by the American Venous Forum (AVF), the Society for Vascular Surgery (SVS), the American College of Phlebology (ACP), the Society for Vascular Medicine (SVM), and the International Union of Phlebology (IUP).

38. Specialty-matched clinical peer review. Revision History Company(ies) DATE REVISION EmblemHealth May 5, 2025 Added Medicaid coverage of endovenous mechanochemical ablation and subfascial endoscopic perforator vein surgery ConnectiCare Feb. 14, 2025 Transferred policy content to individual company branded template EmblemHealth ConnectiCare Feb. 14, 2025 Changed timeframe from 6 mos. to 90 days RE recurrent episodes of superficial thrombophlebitis and/or persistent symptoms interfering with activities of daily living
    Removed 3 mo. trial of conservative non-operative treatment (leg elevation, compression stockings) as a prerequisite for procedures Removed note stipulating that there should be no thrombosis that would interfere with intraluminal procedures Removed note stipulating that sclerotherapy should not occur sooner than 3 mos. after an ablation procedure Defined prerequisite accessory saphenous reflux time as > 500 msec ConnectiCare May 17, 2024 Added language pertaining to the rationale of a three-month waiting period prior to sclerotherapy (after an ablation procedure has been performed) ConnectiCare May 13, 2022 ConnectiCare adopts clinical criteria of its parent corporation EmblemHealth EmblemHealth

    Mar. 11, 2022 Added clarification note in Limitations/Exclusions communicating that sclerotherapy is medically necessary as an initial therapy when the clinical criteria in the policy are met, and that members are not required to undergo an ablation

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Page 12 of 12 procedure prior to sclerotherapy EmblemHealth

Feb. 12, 2021 Removed prerequisite for submission of photo documentation EmblemHealth

Mar. 13, 2020 Added Cyanoacrylate embolization ablation (medical adhesives) to list of approved procedures in Table 1 EmblemHealth

Mar. 9, 2017 Added MOCA coverage for Medicare members EmblemHealth

Mar. 23, 2017 Clarified that photo submission not required for Medicare members EmblemHealth

Oct. 20, 2016 Clarified Varithena definition and specified indications of usage EmblemHealth

Sept. 9, 2016 Added sclerotherapy using foam (e.g., Varithena) as an option EmblemHealth

Aug. 12, 2016 Maximum allowable vein diameter changed from 12mm to 18mm for RFA