Varicose Vein Treatment and Spider Vein Treatment: Medicare and Other Health Insurance Coverage for Veneous Issues
We are all aware of the rising cost of medical insurance. In particular it is helpful to understand what aspects of vein treatments are covered. Here is a typical coverage statement which might be helpful to become familiar with when considering vein treatments, for, in this case varicose veins and sclerotheraphy. The source for this is Oxford Health Plans – NY
Sclerotherapy for Varicose Veins of the Lower Extremities for Medicare
The services described in Oxford policies are subject to the terms, conditions and limitations of the Member’s contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford’s administrative procedures. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies as well as SecureHorizons and Evercare.
Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member’s plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.
Policy #: OUTPATIENT 035.3 T3
Policy is applicable to:
AARP MedicareComplete, Evercare Plan DH and SecureHorizons MedicareComplete, including Group Retiree Plans underwritten by Oxford Health Plans (NY/NJ/CT), Inc. (CMS Contract Numbers: H0752, H3107 and H3307)
Note: For Commercial Members, refer to policy: Sclerotherapy.
Conditions of Coverage
Benefit Type General benefits package
(Does not apply to non-gatekeeper products) No
Authorization (Precertification always required for inpatient admission) Yes1
Precertification with MD Review Yes
Site(s) of Service
(If not listed, MD Review required) Outpatient, Office
Special Considerations 1Sclerotherapy for varicose veins of the lower extremities is not covered for services rendered by podiatrists.
Description of Service/Assessment/Background Information:
The treatment of choice for moderate to large symptomatic varicose veins is ligation and stripping of the saphenous vein. This procedure has proven to usually have the lowest failure rate. Sclerotherapy is an alternative method of treating varicose veins by injecting sclerosing solutions directly into the abnormal veins. While this can sometimes offer an alternative in the case of varicose veins without significant saphenofemoral or saphenopopliteal incompetence, it is not considered to be as reliable and effective as surgical ligation and stripping.
Injection of the saphenous vein at its junction with the deep venous system has been proposed as an alternative to ligation or saphenectomy, its efficacy lacks significant scientific evidence to support its widespread use. There is currently no consensus on the place of sclerotherapy in the treatment of the long saphenous vein and incompetent perforating veins.
Sclerotherapy of the saphenous vein at its junction with the deep system is not a covered procedure.
Microsclerosis refers to injection of telangiectasiae. This procedure is considered cosmetic and is thus not a covered service.
Non-compressive Sclerotherapy involves injection of a sclerosant into a vein without the application of a compressive dressing. This method has not been shown to be effective in producing long-term obliteration of the incompetent veins.
Compressive sclerotherapy involves injection of the sclerosant into an empty vein (elevated limb) followed by application of a compressive bandage or dressing. This is the most commonly performed sclerotherapy procedure for varicose veins of the lower extremity.
High ligation and Compression sclerotherapy refers to ligation of a truncal junction (saphenofemoral or saphenopopliteal) followed by compressive sclerotherapy of one or more veins.
Duplex ultrasound is often used in conjunction with other non-invasive physiologic testing to characterize the anatomy and physiology of the varicose vein network prior to injection or surgical intervention (CPT 93965). However, duplex scanning (CPT 93970, 93971) has been utilized during the sclerotherapy procedure itself. Its usefulness, in this regard, is limited to the saphenous vein near their junction with the deep system. There is little evidence, in the form of randomized prospective clinical trials to support that ultrasound makes a significant difference in the outcome of injections of varicose veins.
Policy and Rationale:
Oxford will cover Sclerotherapy as indicated in the Treatment/Application Guidelines below.
Oxford will cover sclerotherapy of varicose veins according to the following guidelines:
1. Prior to sclerotherapy, and where clinically appropriate, the patient must have been offered and undergone a 3-6 month trial of medically supervised conservative medical therapy including such measures as leg elevation, compressive elastic stockings (support hose) and weight loss. This must be documented in the medical record.
2. Presuming the foregoing criteria are satisfied, sclerotherapy for varicose veins will be covered for the following clinical indications when any of the following conditions can be attributed to the varicosities:
pain in the affected extremities substantial enough to impair mobility or activities of daily living;
significant recurrent superficial phlebitis;
refractory dependent edema or other complications from venous stasis such as dermatitis.
3. Sclerotherapy will also be covered if performed in conjunction with surgical ligation or stripping procedures in appropriately selected patients.
Documentation required for Precertification:
1. The following code represents a procedure considered to be cosmetic and is therefore not covered by Medicare: 36468 Single or multiple injections of sclerosing solutions, spider veins (telangiectasiae); limb or trunk
2. Noncompressive sclerotherapy is not effective and is therefore not covered by Medicare.
3. Compressive sclerotherapy is indicated for local small to medium symptomatic varices, isolated incompetent perforators, or recurrence of symptomatic varices after adequate surgical removal of varices. It is not considered an appropriate option for large, extensive or truncal varicosities.
4. Ultrasound-monitored or duplex-guided techniques (CPT 76998) for sclerotherapy will not be covered when used in conjunction with injection sclerotherapy techniques. Pre-operative venous studies (CPT 93965, 93970, 93971) will be covered when initially performed to determine the extent of venous valvular incompetence. Additional reimbursement is not available for these or other radiologically guided or monitoring techniques when performed solely to guide the needle or introduce the sclerosant into the varicose vein.
5. Reimbursement is not available at this time for sclerosing of the saphenous vein at its junctions with the deep system.
6. Symptomatic improvement is the primary goal and indicator of a satisfactory outcome. Documentation of recanalization or failure of vein closure without recurrent signs or symptoms does not necessarily indicate a need for additional injections.
Sclerotherapy for varicose veins of the lower extremities is not covered for services rendered by podiatrists.
1. The patient’s medical record must document the following:
a history and physical findings supporting a diagnosis of symptomatic varicose veins
failure of an adequate trial of conservative treatment as described in bullets one and three of the Indications section of this policy.
exclusion of other causes of edema, ulceration and pain in the limbs
performance of appropriate tests to confirm the presence and location of incompetent perforating veins.
location and number of varicosities, level of incompetence of the vein and the veins involved
2. The medical record must also include pre-treatment photographs of the varicose veins.