Medical Policy Updates

Notification of Policy Revisions Effective October 26, 2010 (Posted July 20, 2010)

Medical Policy	Revision
Varicose Veins, Treatment for	Description section extensively revised. The sections for when treatment for varicose veins is and is not covered were reformatted. The following was added to the When Varicose Vein Treatment Is Covered section: "Surgical ligation (including subfascial endoscopic perforator surgery) or endovenous radiofrequency or laser ablation of incompetent perforator veins may be considered medically necessary as a treatment of leg ulcers associated with chronic venous insufficiency when the following conditions have been met: There is demonstrated perforator reflux; AND The superficial saphenous veins (greater, lesser, or accessory saphenous and symptomatic varicose tributaries) have been previously eliminated; AND Ulcers have not resolved following combined superficial vein treatment and compression therapy for at least 3 months; AND The venous insufficiency is not secondary to deep venous thromboembolism." The following statements were added to the When Varicose Vein Treatment Is Not Covered section: "Treatment of symptomatic varicose tributaries when performed either at the same time or following prior treatment of saphenous veins using any other techniques than noted above is considered investigational. Ligation or ablation of incompetent perforator veins performed concurrently with superficial venous surgery is not medically necessary." Also "Endovenous cryoablation of any vein" is investigational and not covered. Definition of "compressive therapy" moved to Policy Guidelines section. Rationale for coverage added to Policy Guidelines section. The following statements were added to the Billing/Coding section: "There is no specific CPT code for transilluminated powered phlebectomy. CPT codes 37765, 37766 or 37799 could be used.If CPT 76942 is used for ultrasound guidance of sclerotherapy of the varicose tributaries, it would be considered either not medically necessary or incidental to the injection procedure". References updated. Notification given 7/20/10 for effective date of 10/26/10.

Medical Policy

Revision

Varicose Veins, Treatment for

Description section extensively revised. The sections for when treatment for varicose veins is and is not covered were reformatted. The following was added to the When Varicose Vein Treatment Is Covered section: "Surgical ligation (including subfascial endoscopic perforator surgery) or endovenous radiofrequency or laser ablation of incompetent perforator veins may be considered medically necessary as a treatment of leg ulcers associated with chronic venous insufficiency when the following conditions have been met: There is demonstrated perforator reflux; AND The superficial saphenous veins (greater, lesser, or accessory saphenous and symptomatic varicose tributaries) have been previously eliminated; AND Ulcers have not resolved following combined superficial vein treatment and compression therapy for at least 3 months; AND The venous insufficiency is not secondary to deep venous thromboembolism." The following statements were added to the When Varicose Vein Treatment Is Not Covered section: "Treatment of symptomatic varicose tributaries when performed either at the same time or following prior treatment of saphenous veins using any other techniques than noted above is considered investigational. Ligation or ablation of incompetent perforator veins performed concurrently with superficial venous surgery is not medically necessary." Also "Endovenous cryoablation of any vein" is investigational and not covered. Definition of "compressive therapy" moved to Policy Guidelines section. Rationale for coverage added to Policy Guidelines section. The following statements were added to the Billing/Coding section: "There is no specific CPT code for transilluminated powered phlebectomy. CPT codes 37765, 37766 or 37799 could be used.If CPT 76942 is used for ultrasound guidance of sclerotherapy of the varicose tributaries, it would be considered either not medically necessary or incidental to the injection procedure". References updated. Notification given 7/20/10 for effective date of 10/26/10.