Highmark Medicare Services

12102, 12202, 12302

MAC Part A & B

L27539

Treatment of Varicose Veins of the Lower Extremities

L27539

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7).  This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after N/A

N/A

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Varicose veins are dilated, tortuous, superficial vessels that result from defective valves within the saphenous veins, from intrinsic weakness of the vein wall, from high intraluminal pressure, or on rare occasion, from arteriovenous fistulae. Varicose veins of the lower extremities protrude from the skin surface in a rope-like manner.

Spider veins are capillary veins and are also known as telangiectasias. Spider veins have a web-like appearance on the surface of the skin. Treatment of these superficial veins is most commonly provided for cosmetic purposes, and therefore are not covered.

Indications

Varicose Vein Ligation and Excision (stripping)

Varicose vein ligation and excision (stripping) may be medically necessary when all of the following three conditions are met:

1. A documented three-month trial of conservative therapy ordered by the treating physician including graduated, elasticised compression stockings (with proper instruction on their use), mild exercise, periodic leg elevation, and weight reduction, as appropriate. Compression stockings are defined as graduated elasticized compression stockings. Use of non-graduated compression garments such as support pantyhose does not fulfill this requirement. Lack of patient compliance with compression stockings does not support the need for intervention without documentation of other failed conservative treatments as well. Conservative treatment should include adequate instruction on weight reduction, daily exercise (e.g., a walking plan) and leg elevation.
2. Duplex studies of the venous system performed by an accredited vascular technician that fully defines the anatomy, size and tortuosity of the greater and lesser saphenous vein, superficial venous segments and perforators. These studies must demonstrate both of the following:
   • Absence of deep venous thrombosis.
   • Greater and/or lesser saphenous vein valvular incompetence/reflux that correlates with the patient's symptoms.
3. The patient is symptomatic with varicosities causing any one or more of the following despite conservative therapy:
   • Pain or burning in the extremity substantial enough to impair mobility
   • Persistent symptoms such as aching, cramping, burning, pain, itching and/or swelling during activity or after prolonged standing. Symptoms must be of a severity that they interfere with activities of daily living.
   • Veins are demonstrable (bulging) above the surface of the skin
   • Significant, recurrent superficial phlebitis.
   • Hemorrhage from a ruptured varix.
   • Non-healing skin ulceration of the leg.
   • Refractory dependent edema or other complications from venous stasis such as dermatitis.

Ambulatory or Stab Phlebectomy

Ambulatory or stab phlebectomy is considered medically necessary for treatment of persons who meet medical necessity criteria for varicose vein surgical stripping described above and whose symptoms and functional problems are attributable only to the secondary, smaller vessels.

Injection/Compression Sclerotherapy

Injection/compression sclerotherapy is considered medically necessary for treatment of small to medium sized veins (3-6 mm diameter) for persons who meet medical necessity criteria for varicose vein surgical stripping described above. Sclerotherapy, with or without ultrasound guidance, is not considered effective for treatment of the saphenofemoral junction or the saphenous veins because sclerotherapy has been shown to be ineffective for treatment of these large veins. Sclerotherapy alone has not been shown to be effective and is not covered for persons with reflux at the saphenofemoral or saphenopopliteal junctions. Additionally, non-compressive sclerotherapy is not covered because this method has not been shown effective in producing long-term obliteration of the incompetent veins.

Symptomatic improvement is the primary goal and indicator of a satisfactory outcome. Documentation of recanalization or failure of vein closure without recurrent signs and symptoms does not necessarily indicate a need for additional injections.

Surgical ligation and excision may be covered as part of a combination procedure with sclerotherapy.

Ultrasound or duplex scanning is considered medically necessary when initially performed to determine the extent and configuration of varicose veins. However, ultrasound or radiologically guided or monitoring techniques are not considered medically necessary and are not separately payable when performed solely to guide the needle or introduce the sclerosant into the varicose veins.

In addition to the criteria stated for surgical treatment of varicose veins all of these additional criteria must also be met for authorization of sclerotherapy:

• There is no sapheno-femoral insufficiency, incompetency, or occlusion of the deep system
• Varicosities are at least 3 millimeters in size

Radiofrequency Endovenous Occlusion (EFRA) and Endovenous Laser Ablation

Either radiofrequency EFRA or endovenous laser ablation (with intraoperative ultrasound, as necessary) may be medically necessary as an alternative to varicose vein stripping for patients who meet the medical necessity criteria set forth above. To be considered for coverage of these procedures requires that all of the following criteria be met:

• Patient's anatomy is amenable to laser or radiofrequency catheter and absence of vein tortuosity that would impair catheter advancement.
• Non-aneurysmal saphenous vein(s).
• Maximum saphenous vein diameter is 12 millimeters (only for ERFA).

Subfascial Endoscopic Perforator Vein Surgery

Subfascial Endoscopic Perforator Vein Surgery (SEPS) may be medically necessary for the treatment of patients who meet medical necessity criteria for varicose vein surgical stripping described above as demonstrated by chronic venous insufficiency secondary to primary valvular incompetence of superficial and perforating veins, with or without deep venous incompetence, when conservative management has failed.

SEPS for the treatment of post-thrombotic syndrome or varicose veins is considered investigational/experimental because its effectiveness for these indications has not been established. Therefore, SEPS is non-covered for treatment of post-thrombotic syndrome.

Limitations

All methods of treatment for asymptomatic varicose veins, superficial telangiectasias, spider veins, and other superficial vascular anomalies (including sclerotherapy, photothermal sclerosis also known as Vasculight®, and all forms of laser treatments are considered cosmetic in nature and are not covered. Specifically, CPT/HCPCS codes 36468 and 36469 are non-covered.

The injection of sclerosing solution into telangiectases (intralesional injections), such as spider veins, hemangiomata and angiomata, regardless of the anatomical site (e.g., trunk, limb, or face), is a non-covered service. Treatment of these superficial veins is most commonly provided for beautifying purposes, and therefore, is cosmetic in nature. These procedures should be reported with code 36468 or 36469, as appropriate.

If it is determined on review that the veins treated were spider veins, or that the varicose veins were asymptomatic, the claim will be denied as a noncovered (cosmetic) procedure.

Transdermal laser treatment of large varicose veins has not been proven in direct comparative studies to be as effective as sclerotherapy and/or ligation and vein stripping in the treatment of the larger varicose veins associated with significant symptoms (pain, ulceration, inflammation). Thus, transdermal laser treatment of large symptomatic varicose veins is not covered.

CPT code 37700 will be denied as not reasonable and necessary if it is determined that a percutaneous suture was placed instead of a true ligation.

Although a doppler ultrasound or duplex scan may be required prior to the treatment to characterize the venous anatomy and pathology, additional or other claims for doppler ultrasound or duplex scans used for guidance or monitoring during sclerotherapy will be denied as not medically necessary.

Surgical Services

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.
   
   
4. A clear and definitive history and physical that describes the symptoms and physical characteristics of varicose veins as required in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy must be submitted.
   
   
5. Description of and failure of an adequate trial of conservative treatment (documentation must show at least a three-month trial and documented patient compliance) as required in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy.
   
   
6. Exclusion of other causes of edema, ulceration and pain in the limbs, and description of clinical steps taken to exclude same.
   
   
7. Performance of and results of appropriate tests (including required ultrasonic examination) to confirm the presence and location of incompetent perforating veins.
   
   
8. The details of the operative procedure must be described including the number, location and diameter of each vessel treated.
   
   
9. If additional procedures are performed on the same vessel(s) at a future date, documentation must show a recurrence of signs and symptoms, which are specifically caused by that vessel. Otherwise, the procedure must be considered cosmetic.
   
   
10. For radiofrequency or laser treatment, the patient's operative report, medical treatment history, and progress notes must clearly indicate that all initial and procedural coverage criteria are met as outlined under the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27539

05/22/2008

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