Humana Varicose Vein Treatments Form

. Varicose veins are abnormally enlarged and tortuous vessels greater than three millimeters (3 mm) in diameter that usually result from reflux of blood caused by incompetent valves in the venous system. Rather than flowing forward, blood flows backward across the faulty valve and the resulting increased pressure causes the vein to dilate. The condition is further aggravated with the weakening of the affected vein's walls. Abnormal dilation may affect small reticular or feeder veins as well as superficial veins, located within or just below the skin. Perforator veins penetrate the deep fascia of muscles to form a connection between a deep venous system and a superficial one. They, or other larger veins that may communicate with the saphenous system, may become dilated and tortuous as their valves fail. This may occur anywhere on the leg between the groin and ankle Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 2 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. and is commonly the result of reflux through the valve at the junction between the great saphenous vein (GSV) and the common femoral vein (saphenofemoral junction [SFJ]), or as a result of reflux through the valve at the junction between the small saphenous vein (SSV) and the popliteal vein (saphenopopliteal junction [SPJ]). Perforator veins are considered incompetent with a diameter greater than or equal to 3.5 mm. Perforator reflux, when identified in isolation (without saphenous or deep venous reflux) may give rise to clusters of varicose veins. When combined saphenous and perforator reflux are identified, saphenous reflux is generally treated first which may resolve perforator reflux. Incompetent perforators identified by duplex ultrasonography may be corrected at the time of saphenous ablation or at a later time. Staging treatment phases allows for reevaluation of perforators for persistent incompetence following correction of saphenous reflux. Recommendations for noninvasive management of varicose vein symptoms generally include daily exercise (walking), leg elevation (3 times daily for 30 minutes), leg exercises (ankle flexion) when seated and weight management. Prescriptions may be needed for venoactive medication and/or prescription compression hose. Proposed treatments for varicose veins include, but may not be limited to: • Catheter-assisted venous sclerotherapy (KAVS catheter) uses an intravascular catheter with a balloon at the distal end to temporarily block blood flow to the segment of the vein being targeted for sclerotherapy. May also be referred to as endovenous catheter-directed chemical ablation with balloon isolation. (Refer to Coverage Limitations section) • Cryoablation (cryofreezing, cryostripping, cryosurgery, cryotherapy) involves the use of liquid nitrogen or argon gas at extreme cold temperatures to destroy venous tissue. (Refer to Coverage Limitations section) • Cyanoacrylate closure (CAC) (eg, VenaSeal closure system) delivers medical adhesive using ultrasound guidance via a catheter inserted into the target vein. The catheter is withdrawn and pressure is applied to the vein. (Refer to Coverage Limitations Section) See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 3 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. • Endomechanical or mechanochemical ablation (MOCA) (eg, ClariVein) uses an infusion catheter with a rotating wire tip that purports to disperse the infused medication in the bloodstream and to the targeted treatment area on the vessel wall. (Refer to Coverage Limitations section) • Endovenous thermal ablation techniques use heat energy to seal veins: o Endovenous laser ablation or therapy (EVLA or EVLT) utilizes a percutaneous catheter to deliver high-intensity laser light to induce photocoagulation of blood and occlusion of the vein. o Radiofrequency ablation (RFA), endovascular occlusion or endoluminal radiofrequency ablation (eg, ClosureFast [formerly known as Venefit or VNUS Closure system]) involves the delivery of controlled radiofrequency (RF) energy through a catheter inserted into the affected vein. The heat generated by the RF energy causes the vein to contract and become occluded. • Ligation and stripping consists of tying off and/or removing the varicose veins just under the skin, through several small incisions made along the veins. Once the veins are tied off and/or removed, the blood will flow through the deep veins back to the heart. Compression wrap to the leg(s) is used to limit bruising and swelling postoperatively. • Phlebectomy (ambulatory phlebectomy, microphlebectomy, miniphlebectomy, stab phlebectomy) is the surgical removal of veins through a small incision. • Polidocanol endovenous microfoam (PEM) (Varithena) sclerotherapy, is a drug/device combination product that dispenses a liquid sclerosant and low- nitrogen gas under pressure, from a proprietary canister. It purportedly generates foam of consistent density with bubbles more uniform in diameter, theorized to be more cohesive than standard manually prepared foam sclerosant. (Refer to Coverage Limitations Section) • Sclerotherapy (endovenous chemical ablation) involves injecting a liquid or foam sclerosing agent into the targeted varicose vein, which causes irritation to the inner lining of the vein thereby causing it to collapse. After injecting the sclerosing agent, the extremity is tightly wrapped to keep the vein closed and See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 4 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. enhance permanent closure. The body then absorbs the sclerotic tissue. Examples of types of sclerosants include chemical irritants, detergents, and osmotic agents. • Subfascial endoscopic perforator vein surgery (SEPS) is a less invasive alternative to traditional open surgical treatment of chronic venous insufficiency. An endoscope is inserted into a small incision away from an ulcer site and balloon dissection is performed, with clips or scalpel interrupting incompetent perforator veins in the calf. • Transilluminated powered phlebectomy (TIPP) involves endoscopic resection and ablation of superficial varicosities using an illuminator for vein identification and a powered resector that ablates the vein from underneath. (See Coverage Limitations Section) Coverage Determination When multiple procedures are requested, the criteria for each must be met. General Criteria for Varicose Vein Treatments The general criteria for varicose vein treatments apply to all requests for treatment except sclerotherapy, phlebectomy for recurrent varicosities. Specific treatments may require additional criteria to be met. Humana members may be eligible under the Plan for varicose vein treatments when the following general criteria are met: • Absence of contraindications; AND • Duplex ultrasound or Doppler imaging study report shows clinically significant reflux (incompetence), indicated by greater than or equal to 500 milliseconds (ms) (0.5 seconds) of the great saphenous vein or the small saphenous vein or perforator veins7 in the extremity to be treated; AND documentation in the clinical records of at least one of the following: o Hemorrhage from venous varicosity; OR See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 5 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. o Venous stasis ulceration; OR o Symptoms of venous insufficiency of the lower extremities (ache, pain, muscle cramps, heaviness, edema, tightness) causing a functional impairment* which interferes with activities of daily living, despite a trial of nonprescription or prescription analgesics if medically appropriate and not contraindicated; AND o Symptoms persist despite a trial of at least 3 consecutive months of compliance with compressive stockings providing 20 to 30 mm Hg pressure *Functional impairment means a direct and measurable reduction in physical performance of an organ or body part. Criteria for Specific Treatments Unless noted otherwise, the following treatments must meet the above General Criteria for Varicose Vein Treatments for varicose vein treatments in addition to the individual criteria outlined below for each treatment. Ligation and Stripping Humana members may be eligible under the Plan for ligation and stripping of varicose great or small saphenous veins or perforator veins when the above General Criteria for Varicose Vein Treatments are met. There are no additional criterion requirements. EVLA, EVLT, RFA of Great or Small Saphenous Veins Humana members may be eligible under the Plan for EVLA, EVLT or RFA of the great or small saphenous veins when the above General Criteria for Varicose Vein Treatments are met; AND • Initially, one session of endovascular treatment (EVLA, EVLT or RFA) of the great saphenous vein and one session of endovascular treatment of the small saphenous vein, of the affected extremity, may be approved; AND See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 6 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. • A session may include treatment of multiple veins in one or both legs on a single date of service; AND • Commercial Plan members: requests beyond ONE session of endovascular treatment (EVLA, EVLT or RFA) of the great saphenous vein and one session of endovascular treatment of the small saphenous vein, of the affected extremity, require review by a medical director Initial/Adjunctive Sclerotherapy, Phlebectomy (performed at the same time as, or shortly after EVLA, EVLT, RFA or surgical ligation and stripping) The use of ultrasound guidance during a procedure (echosclerotherapy, endovenous chemical ablation, ultrasound-guided sclerotherapy) is considered integral to the primary procedure and not separately reimbursable. Humana members may be eligible under the Plan for sclerotherapy OR phlebectomy OR a combination thereof, to treat symptomatic varicose tributary, perforator or accessory veins when the above General Criteria for Varicose Vein Treatments are met; AND • Sclerotherapy OR phlebectomy OR a combination thereof, is used in conjunction with treatment of saphenous incompetence by EVLA, EVLT, RFA or surgical ligation and stripping of the saphenous system; AND o Initially, up to three total sessions of treatment with sclerotherapy OR phlebectomy OR a combination thereof, per leg, may be approved; AND o Must be completed within 90 days of the first date of service (for EVLA, EVLT, RFA or surgical ligation and stripping); AND o A session includes treatment(s) rendered on one date of service; AND See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 7 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. o Commercial Plan members: requests beyond THREE total sessions of treatment per leg, with sclerotherapy OR phlebectomy OR a combination thereof, require review by a medical director Sclerotherapy, Phlebectomy for Recurrent Varicosities (General Criteria for Varicose Vein Treatments does NOT apply) Humana members may be eligible under the Plan for sclerotherapy OR phlebectomy OR a combination thereof, to treat recurrent symptomatic varicose tributary, perforator or accessory veins when the following criteria are met: • Absence of contraindications; AND • Duplex scan report provides evidence of recurrent and clinically significant varicose veins (reflux greater than or equal to 500 ms [0.5 seconds]) AND at least one of the following: o Hemorrhage from venous varicosity; OR o Venous stasis ulceration; OR o Symptoms of venous insufficiency of the lower extremities (ache, pain, muscle cramps, heaviness, edema, tightness) causing a functional impairment* which interferes with activities of daily living despite a trial of nonprescription or prescription analgesics if medically appropriate and not contraindicated; AND o Sclerotherapy OR phlebectomy OR a combination thereof, is being used to treat recurrent varicosities in extremities previously treated with EVLA, EVLT, RFA or surgical ligation and stripping; AND  Approvals for sessions of sclerotherapy, phlebectomy or a combination thereof are limited to three per leg; AND  A session includes treatment(s) rendered on one date of service; AND See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 8 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.  Commercial Plan members: requests beyond THREE total sessions of treatment per leg, with sclerotherapy OR phlebectomy OR a combination thereof, require review by a medical director. The use of ultrasound guidance during the procedure (echosclerotherapy, endovenous chemical ablation, ultrasound-guided sclerotherapy) is considered integral to the primary procedure and not separately reimbursable. SEPS Humana members may be eligible under the Plan for SEPS to treat symptomatic varicose perforator veins when the following criteria are met: • Duplex ultrasound or Doppler imaging study report shows clinically significant reflux where the outward flow of duration is greater than or equal to 500 ms (0.5 seconds); AND • Perforator vein diameter is greater than or equal to 3.5 mm; AND • The vein to be treated is located beneath a healed or open venous ulcer (Clinical, Etiology, Anatomy and Pathology [CEAP] classification of chronic venous disorders, class C5 - C6)7 Coverage Limitations Humana members may NOT be eligible under the Plan for the treatment of varicose veins by the following methods for any indication: • Catheter-assisted venous sclerotherapy (KAVS catheter) (also referred to as endovenous catheter-directed chemical ablation with balloon isolation); OR • Cryoablation (also referred to as cryofreezing, cryostripping, cryosurgery, cryotherapy); OR • Cyanoacrulate closure (CAC) (eg, VenaSeal closure system; OR • Endomechanical or mechanochemical ablation (MOCA) (eg, ClariVein); OR See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 9 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. • Polidocanol endovenous microfoam (PEM) (Varithena); OR • TIPP; OR • Treatment in the presence of any of the following procedure-specific contraindications: o EVLA/EVLT – arterial insufficiency (eg, ankle-brachial index of less than 0.9) or pregnancy or thrombosis o RFA – arterial insufficiency (eg, ankle-brachial index of less than 0.9) or pregnancy or thrombosis or venous aneurysm o Sclerotherapy – allergy to sclerosant, arterial insufficiency (eg, ankle-brachial index of less than 0.9) or infection (local or systemic) or pregnancy or thrombosis These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language. Humana members may NOT be eligible under the Plan for treatment of telangiectasias (spider veins, venules, reticular veins, superficial capillaries) by any method including, but not limited to: • Intense pulsed light (also referred to as photothermal sclerosis) (eg, Lumenis IPL with OPT; OR • Transdermal laser treatment; OR • VeinGogh Ohmic Thermolysis System These are considered cosmetic. Please refer to the member’s individual certificate for the specific definition. Humana members may NOT be eligible under the Plan for the treatment of varicose veins for any indications other than those listed above or for the following: See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 10 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. • Phlebectomy as the initial sole treatment of perforator vein incompetence; OR • RFA or EVLA/EVLT of varicose tributaries, accessory veins and perforator veins; OR • Sclerotherapy as the initial sole treatment of perforator vein incompetence; OR • Sclerotherapy as the sole treatment of the great saphenous vein or small saphenous vein for incompetence; OR • Sclerotherapy OR phlebectomy OR a combination thereof as the sole treatment of tributary or accessory veins without associated treatment of saphenous incompetence; OR These indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition. Additional duplex ultrasound or Doppler imaging studies for monitoring purposes and/or to assess treatment progress within the initial 90 day treatment period are not separately reimbursable. Duplex ultrasound or Doppler imaging studies necessary for a procedure-related complication MAY be considered separately reimbursable. Background Additional information about venous insufficiency and varicose veins may be found from the following websites: • American Vein and Lymphatic Society • American Venous Forum • National Library of Medicine • Society for Vascular Surgery See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 11 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Medical Alternatives Physician consultation is advised to make an informed decision based on an individual’s health needs. Humana may offer a disease management program for this condition. The member may call the number on his/her identification card to ask about our programs to help manage his/her care. Provider Claims Codes Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure. CPT® Code(s) 36465 36466 36468 36470 36471 36473 Description Comments 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) 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 Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk Injection of sclerosant; single incompetent vein (other than telangiectasia) Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated Not Covered Not Covered Not Covered Not Covered See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 12 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 36474 36475 36476 36478 36479 36482 36483 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) Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated 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 (List separately in addition to code for primary procedure) Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated 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) 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 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) Not Covered Not Covered Not Covered See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 13 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS) Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions Ligation, division, and stripping, short saphenous vein Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below 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 Ligation of perforator veins, subfascial, radical (Linton type), including skin graft, when performed, open,1 leg Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure) Ligation, division, and/or excision of varicose vein cluster(s), 1 leg 37241 37500 37700 37718 37722 37735 37760 37761 37765 37766 37780 37785 37799 Unlisted procedure, vascular surgery Not Covered if used to report any treatment outlined in Coverage Limitations section Not Covered if used to report any treatment outlined in Coverage Limitations section See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 14 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 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 Considered integral to primary procedure when used in conjunction with echosclerotherapy, endovenous chemical ablation, or ultrasound- guided sclerotherapy No additional reimbursement provided if performed for monitoring purposes and/or to assess treatment progress within the initial 90 day treatment period No additional reimbursement provided if performed for monitoring purposes and/or to assess treatment progress within the initial 90 day treatment period CPT® Category III Code(s) 0524T HCPCS Code(s) S2202 Description Comments 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 Not Covered Description Comments Echosclerotherapy See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 15 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. References 1. 2. 3. 4. 5. 6. 7. American Vein and Lymphatic Society. Position Statement. Cyanoacrylate venous closure. https://www.myavls.org. Updated February 28, 2019. Accessed January 6, 2023. American Vein and Lymphatic Society. Position Statement. Mechanochemical venous ablation. https://www.myavls.org. Published January 7, 2019. Accessed January 6, 2023. American Vein and Lymphatic Society. Position Statement. Non-compounded foam sclerotherapy. https://www.myavls.org. Published October 12, 2018. Updated January 8, 2019. Accessed January 6, 2023. American Vein and Lymphatic Society. Practice Guidelines. Duplex ultrasound imaging of lower extremity veins in chronic venous disease, exclusive of deep venous thrombosis: guidelines for performance and interpretation of studies. https://www.myavls.org. Published June 2012. Accessed January 6, 2023. American Vein and Lymphatic Society. Practice Guidelines. Superficial venous disease: treatment of superficial venous disease of the lower leg. https://www.myavls.org. Published February 2016. Accessed January 6, 2023. American Venous Forum (AVF). The 2020 appropriate use criteria for chronic lower extremity venous disease of the American Venous Forum, the Society for Vascular Surgery, the American Vein and Lymphatic Society, and the Society of Interventional Radiology. https://www.veinforum.org. Published July 2020. Accessed January 6, 2023. ClinicalKey. Glovicki P, Lawrence P, Wasan S, et al. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex scanning and treatment of superficial truncal reflux. J Vasc Surg Venous Lymphat Disord. 2023;11:231-61. https://www.clinicalkey.com. Accessed March 1, 2023. 8. ClinicalKey. Iafrati MD. Varicose veins: surgical treatment. In: Sidawy AN, Perler BA. Rutherford’s Vascular Surgery and Endovascular Therapy, 10th ed. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 16 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Elsevier; 2023:2031-2048.e2. https://www.clinicalkey.com. Accessed January 5, 2023. 9. ClinicalKey. Lurie F, Puggioni A, Russell T. Chronic venous insufficiency: treatment of perforator vein incompetence. In: Sidawy AN, Perler BA. Rutherford’s Vascular Surgery and Endovascular Therapy, 10th ed. Elsevier; 2023:2085-2097.e2. https://www.clinicalkey.com. Accessed January 5, 2023. 10. ClinicalKey. Sadek M, Kabnick L. Varicose veins: endovenous ablation and sclerotherapy. In: Sidawy AN, Perler BA. Rutherford’s Vascular Surgery and Endovascular Therapy, 10th ed. Elsevier; 2023:2049-2062.e4. https://www.clinicalkey.com. Accessed January 5, 2023. 11. ECRI Institute. Clinical Evidence Assessment. Varithena injectable foam (Boston Scientific Corp.) for treating varicose veins. https://www.ecri.org. Published January 16, 2015. Updated December 11, 2020. Accessed December 21, 2022. 12. ECRI Institute. Clinical Evidence Assessment. VenaSeal closure system (Medtronic plc.) for embolizing varicose veins. https://www.ecri.org. Published March 10, 2015. Updated February 4, 2021. Accessed December 21, 2022. 13. ECRI Institute. Hotline Response. Compression stockings for the initial treatment of varicose veins. https://www.ecri.org. Published December 31, 2019. Accessed December 21, 2022. 14. ECRI Institute. Hotline Response (ARCHIVED). Transilluminated powered phlebectomy (TIPP) for varicose veins. https://www.ecri.org. Published April 7, 2004. Updated September 9, 2011. Accessed December 21, 2022. 15. ECRI Institute. Product Brief (ARCHIVED). ClariVein infusion catheter (Vascular Insights, LLC) for peripheral vascular interventions. https://www.ecri.org. Published June 20, 2017. Accessed December 21, 2022. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 17 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 16. Hayes, Inc. Evidence Analysis Research Brief. Subfascial endoscopic perforator surgery for treatment of venous ulcers. https://evidence.hayesinc.com. Published January 25, 2023. Accessed March 4, 2023. 17. Hayes, Inc. Evidence Analysis Research Brief (ARCHIVED). Routine duplex ultrasound for detection of thrombosis after endovenous ablation procedures. https://evidence.hayesinc.com. Published August 19, 2019. Accessed December 23, 2021. 18. Hayes, Inc. Health Technology Assessment. Cyanoacrylate embolization with the VenaSeal Closure System (Medtronic, Inc.) for the treatment of varicose veins. https://evidence.hayesinc.com. Published September 2, 2022. Accessed December 21, 2022. 19. Hayes, Inc. Health Technology Assessment. Mechanochemical endovenous ablation (MOCA) with the ClariVein Infusion Catheter nonthermal vein ablation system (Merit Medical System, Inc.) for treatment of varicose veins. https://evidence.hayesinc.com. Published February 25, 2022. Updated March 16, 2023. Accessed December 21, 2022. 20. Hayes, Inc. Health Technology Assessment. Polidocanol endovenous microfoam (Varithena) 1% for treatment of varicose veins. https://evidence.hayesinc.com. Published September 16, 2019. Updated November 10, 2022. Accessed December 21, 2022. 21. Hayes, Inc. Health Technology Brief (ARCHIVED). Ultrasound-guided foam sclerotherapy (UGFS) for varicose veins. https://evidence.hayesinc.com. Published November 4, 2011. Updated December 9, 2013. Accessed December 21, 2022. 22. Hayes, Inc. Medical Technology Directory (ARCHIVED). Comparative effectiveness of endovenous laser therapy versus conventional surgery for symptomatic varicose veins: a review of reviews. https://evidence.hayesinc.com. Published September 7, 2017. Updated October 11, 2021. Accessed December 21, 2022. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 18 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 23. Hayes, Inc. Medical Technology Directory (ARCHIVED). Comparative effectiveness of endovenous radiofrequency ablation versus conventional surgery for symptomatic varicose veins: a review of reviews. https://evidence.hayesinc.com. Published October 17, 2017. Updated November 29, 2021. Accessed December 21, 2022. 24. MCG Health. Graduated compression stockings. 26th edition. https://www.mcg.com. Accessed November 7, 2022. 25. MCG Health. Saphenous vein ablation, adhesive injection. 26th edition. https://www.mcg.com. Accessed November 7, 2022. 26. MCG Health. Saphenous vein ablation, laser. 26th edition. https://www.mcg.com. Accessed November 7, 2022. 27. MCG Health. Saphenous vein ablation, mechanical occlusion chemical ablation (MOCA). 26th edition. https://www.mcg.com. Accessed November 7, 2022. 28. MCG Health. Saphenous vein ablation, radiofrequency. 26th edition. https://www.mcg.com. Accessed November 7, 2022. 29. MCG Health. Saphenous vein stripping. 26th edition. https://www.mcg.com. Accessed November 7, 2022. 30. MCG Health. Sclerotherapy, leg veins. 26th edition. https://www.mcg.com. Accessed November 7, 2022. 31. MCG Health. Sclerotherapy plus ligation, saphenofemoral junction. 26th edition. https://www.mcg.com. Accessed November 7, 2022. 32. MCG Health. Stab phlebectomy. 26th edition. https://www.mcg.com. Accessed November 7, 2022. 33. Merck Manual: Professional Version. Varicose veins. https://www.merckmanuals.com. Updated September 2022. Accessed January 5, 2023. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 19 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 34. UpToDate. Approach to treating symptomatic superficial venous insufficiency. https://www.uptodate.com. Updated December 2022. Accessed January 3, 2023. 35. UpToDate. Classification of lower extremity chronic venous disorders. https://www.uptodate.com. Updated December 2022. Accessed January 3, 2023. 36. UpToDate. Clinical manifestations of lower extremity chronic venous disease. https://www.uptodate.com. Updated December 2022. Accessed January 3, 2023. 37. UpToDate. Comparison of methods for endovenous ablation for chronic venous disease. https://www.uptodate.com. Updated December 2022. Accessed January 3, 2023. 38. UpToDate. Compression therapy for the treatment of chronic venous insufficiency. https://www.uptodate.com. Updated December 2022. Accessed January 3, 2023. 39. UpToDate. Injection sclerotherapy techniques for the treatment of telangiectasias, reticular veins and small varicose veins. https://www.uptodate.com. Updated December 2022. Accessed January 3, 2023. 40. UpToDate. Laser and light therapy of lower extremity telangiectasias, reticular veins and small varicose veins. https://www.uptodate.com. Updated December 2022. Accessed January 3, 2023. 41. UpToDate. Medical management of lower extremity chronic venous disease. https://www.uptodate.com. Updated December 2022. Accessed January 3, 2023. 42. UpToDate. Nonthermal, nontumescent ablation techniques for the treatment of lower extremity superficial venous insufficiency. https://www.uptodate.com. Updated December 2022. Accessed January 3, 2023. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 20 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 43. UpToDate. Open surgical techniques for lower extremity vein ablation. https://www.uptodate.com. Updated December 2022. Accessed January 3, 2023. 44. UpToDate. Overview of lower extremity chronic venous disease. https://www.uptodate.com. Updated December 2022. Accessed January 3, 2023. 45. UpToDate. Stasis dermatitis. https://www.uptodate.com. Updated December 2022. Accessed January 3, 2023. 46. UpToDate. Superficial vein thrombosis and phlebitis of the lower extremity veins. https://www.uptodate.com. Updated December 2022. Accessed January 3, 2023. 47. UpToDate. Techniques for endovenous laser ablation for the treatment of lower extremity chronic venous disease. https://www.uptodate.com. Updated December 2022. Accessed January 3, 2023. 48. UpToDate. Techniques for radiofrequency ablation for the treatment of lower extremity chronic venous disease. https://www.uptodate.com. Updated December 2022. Accessed January 3, 2023. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Varicose Vein Treatments Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0318-028 Page: 21 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Appendix A CEAP Classification7 Clinical classification C0 C1 C2 No visible or palpable signs of venous disease Telangiectasias, reticular veins, malleolar flares Varicose veins C2r Recurrent varicose veins C3 C4 Edema without skin changes Changes in skin and subcutaneous tissue due to chronic venous insufficiency C4a Pigmentation or eczema C4b Lipodermatosclerosis or atrophie blanche C4c Corona phlebectatica (abnormally dilated veins around ankle) C5 C6 Healed venous ulcer Active venous ulcer C6r Recurrent active venous ulcer See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.