Varicose Veins and Venous Insufficiency Form

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Treatment for Varicose Veins and Venous Insufficiency - Medical Policy
Updated Revision Effective July 1, 2025 Policy Number:

UM727POL

Approval Date: 8/1/2025

Line(s) of Business:

Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Varicose veins are caused by venous insufficiency as a result of valve reflux (incompetence). The venous insufficiency results in dilated, tortuous, superficial vessels that protrude from the skin of the lower extremities.
Spider veins (telangiectasias) are dilated capillary veins that are most often treated for cosmetic purposes.

Treatment of venous reflux/venous insufficiency is aimed at reducing abnormal pressure transmission from the deep to the superficial veins. Conservative medical treatment consists of elevation of the extremities, graded compression, and wound care when indicated. Conventional surgical treatment consists of identifying and correcting the site of reflux by ligation of the incompetent junction followed by stripping of the vein to redirect venous flow through veins with intact valves. While most venous reflux is secondary to incompetent valves at the saphenofemoral or saphenopopliteal junctions, reflux may also occur at incompetent valves in the perforator veins or in the deep venous system. The competence of any single valve is not static and may be pressure dependent. For example, accessory saphenous veins may have independent saphenofemoral or saphenopopliteal junctions that become incompetent when the great or small saphenous veins are eliminated, and blood flow is diverted through the accessory veins.

Treatments for eliminating saphenous (great saphenous vein (GSV), anterior accessory GSV (AAGSV), small saphenous vein (SSV)) reflux (saphenofemoral or saphenopopliteal) are radiofrequency ablation (RFA), laser ablation (EVLA), polidocanol microfoam (PEM), cyanoacrylate embolization (CAE) ablation, and mechanochemical ablation (MOCA).

 Line of Business

Commercial:

• HNE has adopted InterQual* criteria for the following procedures:

o Cyanoacrylate Closure (CAC):

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➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Perforator Vein

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Superficial Truncal Vein

o Endovenous Ablation:

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Perforator Vein

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Superficial Truncal Vein

o Endovenous Laser Ablation (EVLA):

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Perforator Vein

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Superficial Truncal Vein

o Endovenous Nonthermal Ablation:

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Perforator Vein

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Superficial Truncal Vein

o Endovenous Thermal Ablation:

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Perforator Vein

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Superficial Truncal Vein

o Mechanochemical Ablation (MOCA):

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Perforator Vein

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Superficial Truncal Vein

o Radiofrequency Ablation (RFA):

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Perforator Vein

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➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Superficial Truncal Vein

o Ultrasound-Guided Foam Sclerotherapy (UGFS):

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Perforator Vein

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Superficial Truncal Vein

o Ambulatory Phlebectomy:

➢ CP:Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein, Phlebectomy, Superficial Tributary Varicose Vein

o Ambulatory Selective Variceal Ablation Under Local Anesthesia (ASVAL):

➢ CP:Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein, Phlebectomy, Superficial Tributary Varicose Vein

o Hook Phlebectomy:

➢ CP:Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein, Phlebectomy, Superficial Tributary Varicose Vein

o Microphlebectomy:

➢ CP:Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein, Phlebectomy, Superficial Tributary Varicose Vein

o Mini Phlebectomy:

➢ CP:Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein, Phlebectomy, Superficial Tributary Varicose Vein

o Stab Avulsion:

➢ CP:Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein, Phlebectomy, Superficial Tributary Varicose Vein

o Stab Phlebectomy:

➢ CP:Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein, Phlebectomy, Superficial Tributary Varicose Vein

o Transilluminated Powered Phlebectomy (TIPP)

➢ CP:Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein, Phlebectomy, Superficial Tributary Varicose Vein

o Ligation and division with or without stripping or excision

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➢ CP:Procedures: Ligation and Division +/- Stripping or Excision, Lower Extremity Superficial Vein, Ligation and Division +/- Stripping or Excision, Superficial Vein

o Foam Sclerotherapy

➢ CP:Procedures: Sclerotherapy, Lower Extremity Superficial Tributary Varicose Vein, Sclerotherapy, Superficial Tributary Varicose Vein

o Microfoam Sclerotherapy

➢ CP:Procedures: Sclerotherapy, Lower Extremity Superficial Tributary Varicose Vein, Sclerotherapy, Superficial Tributary Varicose Vein

o Ultrasound-Guided Foam Sclerotherapy (UGFS)

➢ CP:Procedures: Sclerotherapy, Lower Extremity Superficial Tributary Varicose Vein, Sclerotherapy, Superficial Tributary Varicose Vein

Medicaid – BeHealthy:

• HNE has adopted InterQual* criteria for the following procedures:

o Cyanoacrylate Closure (CAC):

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Perforator Vein

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Superficial Truncal Vein

o Endovenous Ablation:

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Perforator Vein

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Superficial Truncal Vein

o Endovenous Laser Ablation (EVLA):

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Perforator Vein

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Superficial Truncal Vein

o Endovenous Nonthermal Ablation:

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➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Perforator Vein

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Superficial Truncal Vein

o Endovenous Thermal Ablation:

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Perforator Vein

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Superficial Truncal Vein

o Mechanochemical Ablation (MOCA):

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Perforator Vein

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Superficial Truncal Vein

o Radiofrequency Ablation (RFA):

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Perforator Vein

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Superficial Truncal Vein

o Ultrasound-Guided Foam Sclerotherapy (UGFS):

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Perforator Vein

➢ CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Superficial Truncal Vein

o Ambulatory Phlebectomy:

➢ CP:Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein, Phlebectomy, Superficial Tributary Varicose Vein

o Ambulatory Selective Variceal Ablation Under Local Anesthesia (ASVAL):

➢ CP:Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein, Phlebectomy, Superficial Tributary Varicose Vein

o Hook Phlebectomy:

➢ CP:Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein, Phlebectomy, Superficial Tributary Varicose Vein

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o Microphlebectomy:

➢ CP:Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein, Phlebectomy, Superficial Tributary Varicose Vein

o Mini Phlebectomy:

➢ CP:Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein, Phlebectomy, Superficial Tributary Varicose Vein

o Stab Avulsion:

➢ CP:Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein, Phlebectomy, Superficial Tributary Varicose Vein

o Stab Phlebectomy:

➢ CP:Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein, Phlebectomy, Superficial Tributary Varicose Vein

o Transilluminated Powered Phlebectomy (TIPP)

➢ CP:Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein, Phlebectomy, Superficial Tributary Varicose Vein

o Ligation and division with or without stripping or excision

➢ CP:Procedures: Ligation and Division +/- Stripping or Excision, Lower Extremity Superficial Vein, Ligation and Division +/- Stripping or Excision, Superficial Vein

o Foam Sclerotherapy

➢ CP:Procedures: Sclerotherapy, Lower Extremity Superficial Tributary Varicose Vein, Sclerotherapy, Superficial Tributary Varicose Vein

o Microfoam Sclerotherapy

➢ CP:Procedures: Sclerotherapy, Lower Extremity Superficial Tributary Varicose Vein, Sclerotherapy, Superficial Tributary Varicose Vein

o Ultrasound-Guided Foam Sclerotherapy (UGFS)

➢ CP:Procedures: Sclerotherapy, Lower Extremity Superficial Tributary Varicose Vein, Sclerotherapy, Superficial Tributary Varicose Vein

• There are no MassHealth guidelines for the treatment for varicose veins and venous insufficiency.

Medicare:

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• Health New England follows Local Coverage Determination (LCD) L33575, Varicose Veins of the Lower Extremity, Treatment of. https://www.cms.gov/medicare-coverage-database/search.aspx

*To obtain InterQual® SmartSheets™: If you are a registered Health New England provider click here: https://www.hnedirect.com/login/ to access the Provider website. If you do not have access to the portal call (413) 787-4004 to obtain a copy.

Policy

I. Cyanoacrylate Closure (CAC), Endovenous Ablation, Endovenous Laser Ablation (EVLA), Endovenous Nonthermal Ablation, Endovenous Thermal Ablation, Mechanochemical Ablation (MOCA), Radiofrequency Ablation (RFA), Ultrasound-Guided Foam Sclerotherapy (UGFS)

A. Health New England has adopted following InterQual criteria.

o CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Perforator Vein o CP:Procedures, Endovenous Ablation, Lower Extremity Superficial Truncal or Perforator Vein, Endovenous Ablation, Superficial Truncal Vein

B. For members under 18 years of age, the request will be reviewed on a case-by-case basis.

C. HNE follows Local Coverage Determination (LCD) L33575, Varicose Veins of the Lower Extremity, Treatment of, for Medicare.

D. Cyanoacrylate Closure (CAC), Endovenous Ablation, Endovenous Laser Ablation (EVLA), Endovenous Nonthermal Ablation, Endovenous Thermal Ablation, Mechanochemical Ablation (MOCA), Radiofrequency Ablation (RFA), Ultrasound-Guided Foam Sclerotherapy (UGFS) for all other indications other than in criteria above are considered NOT MEDICALLY NECESSARY.

II. Ambulatory Phlebectomy, Ambulatory Selective Variceal Ablation Under Local Anesthesia (ASVAL), Hook Phlebectomy, Microphlebectomy, Mini Phlebectomy, Stab Avulsion, Stab Phlebectomy, Transilluminated Powered Phlebectomy (TIPP)

A. Health New England has adopted the following InterQual criteria.

o CP: Procedures: Phlebectomy, Lower Extremity Superficial Tributary Varicose Vein, Phlebectomy, Superficial Tributary Varicose Vein

B. For members under 18 years of age, the request will be reviewed on a case-by-case basis.

C. HNE follows MassHealth Guidelines for Medical Necessity Determination for Treatment of Varicose Veins of the Lower Extremities, for Medicaid.

D. HNE follows Local Coverage Determination (LCD) L33575, Varicose Veins of the Lower Extremity, Treatment of, for Medicare.

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E. Ambulatory Phlebectomy, Ambulatory Selective Variceal Ablation Under Local Anesthesia (ASVAL), Hook Phlebectomy, Microphlebectomy, Mini Phlebectomy, Stab Avulsion, Stab Phlebectomy, Transilluminated Powered Phlebectomy (TIPP) for all other indications other than in criteria above are considered NOT MEDICALLY NECESSARY.

III. Ligation and Division +/- Stripping or Excision, Superficial Vein

A. Health New England has adopted the following InterQual criteria.

o CP:Procedures: Ligation and Division +/- Stripping or Excision, Lower Extremity Superficial Vein, Ligation and Division +/- Stripping or Excision, Superficial Vein

B. For members under 18 years of age, the request will be reviewed on a case-by-case basis.

C. HNE follows MassHealth Guidelines for Medical Necessity Determination for Treatment of Varicose Veins of the Lower Extremities, for Medicaid.

D. HNE follows Local Coverage Determination (LCD) L33575, Varicose Veins of the Lower Extremity, Treatment of, for Medicare.

E. Ligation and Division +/- Stripping or Excision, Superficial Vein for all other indications other than in criteria above are considered NOT MEDICALLY NECESSARY.

IV. Foam Sclerotherapy, Microfoam Sclerotherapy, Ultrasound-Guided Foam Sclerotherapy (UGFS)

A. Health New England has adopted following InterQual criteria.

o CP:Procedures: Sclerotherapy, Lower Extremity Superficial Tributary Varicose Vein, Sclerotherapy, Superficial Tributary Varicose Vein

B. For members under 18 years of age, the request will be reviewed on a case-by-case basis.

C. HNE follows Local Coverage Determination (LCD) L33575, Varicose Veins of the Lower Extremity, Treatment of, for Medicare.

D. Foam Sclerotherapy, Microfoam Sclerotherapy, Ultrasound-Guided Foam Sclerotherapy (UGFS) for all other indications other than in criteria above are considered NOT MEDICALLY NECESSARY.

Policy Guidelines and Definitions

Definitions:

Varicose Veins: Abnormally enlarged and tortuous vessels greater than three millimeters in diameter

Endovenous Chemical Ablation: Procedure that utilizes a medical adhesive, which is delivered via a catheter to occlude the targeted vein

Endovenous Laser Ablation: Procedure that utilizes a percutaneous catheter to deliver high-intensity laser light

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to induce photocoagulation of blood and occlusion of the vein

Endovenous Radiofrequency Ablation: Procedure that involves the delivery of controlled radiofrequency energy through a catheter inserted into the affected vein. The heat generated by the radiofrequency energy causes the vein to contract and become occluded.

Ablation: Removal or destruction of a body part, function or tissue via surgery, drugs, RFA, hormones, heat or other methods

Radiofrequency Energy: Energy as radio waves that acts as electrical energy to sculpt, shrink or remove soft tissue

Coding Guidance

Code Description Codes requiring prior authorization
36468 Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk (HNE denies BN) Not Covered 36470 Injection of sclerosant; single incompetent vein (other than telangiectasia) PA 36471 Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg PA 36473 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated PA 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 (List separately in addition to code for primary procedure) PA 36475 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated PA 36476 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites (list separately in addition to code for primary procedure) PA 36478 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated PA

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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) PA 6482 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (e.g., cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated PA 36483 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (e.g., 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) PA 37700 Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions
PA 37718 Ligation, division, and stripping, short saphenous vein

PA 37722 Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below PA 37765 Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions No PA 37766 Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions No PA 37780 Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure)
PA 37785 Ligation, division, and/or excision of varicose vein cluster(s), 1 leg No PA

CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

Local Coverage Determination (LCD) L33575, Varicose Veins of the Lower Extremity, Treatment of.
LCD - Varicose Veins of the Lower Extremity, Treatment of (L33575) (cms.gov)

Policy Implementation

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Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 4/23/2020 Initial policy date 01/2021 No change 09/2022 Removed 36482 and 36483 as non-covered by Mass Health as of 6/1/2022 04/2023 Added prior authorization to 36471, 36473, 36474, 37700, 37718, 37722, and 37780.
Added to non-covered codes for commercial 36482, 36483, 36473 and 36474. Added to non-covered codes for MassHealth 36473 and 36474.
08/2023 Previous title of this policy: “Endovenous Ablation Therapy of Varicose Veins” 1/2024 Line of Business Section added Minor criteria changes. 09/2024 InterQual criteria adopted for commercial lines of business. References updated. CPT 36482 and 36483 status changed from non-covered to covered with PA for commercial line of business.
CPT code 36473 and 36474 changed from non-covered to covered with PA for commercial and MassHealth line of business. InterQual to be followed for these codes. 7/2025 Updated MassHealth criteria to use InterQual for all procedures as MassHealth guidelines are no longer in effect.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England 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).
Health New England 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 Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. 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 the time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.