VARICOSE VEIN PROCEDURES - Health Plan of Nevada

Protocol: SUR037 

Effective Date: September 12, 2011 

VARICOSE VEIN PROCEDURES 

Table of Contents 

Page 

COMMERCIAL INDICATIONS FOR COVERAGE............................................................................. 1 

MEDICARE & MEDICAID COVERAGE RATIONALE...................................................................... 4 

BACKGROUND ...................................................................................................................................... 8 

CLINICAL EVIDENCE........................................................................................................................... 8 

U.S. FOOD AND DRUG ADMINISTRATION (FDA)........................................................................ 10 

APPLICABLE CODES FOR COMMERCIAL COVERAGE .............................................................. 10 

APPLICABLE CODES FOR MEDICARE & MEDICAID COVERAGE ........................................... 11 

REFERENCES ....................................................................................................................................... 13 

QUESTIONNAIRE ................................................................................................................................ 15 

PROTOCOL HISTORY/REVISION INFORMATION ........................................................................ 16 

INSTRUCTIONS FOR USE 

This protocol provides assistance in interpreting UnitedHealthcare benefit plans. When deciding 

coverage, the enrollee specific document must be referenced. The terms of an enrollee's document 

(e.g., Certificate of Coverage (COC) or Evidence of Coverage (EOC) may differ greatly. In the event 

of a conflict, the enrollee's specific benefit document supersedes this protocol. All reviewers must first 

identify enrollee eligibility, any federal or state regulatory requirements and the plan benefit coverage 

prior to use of this Protocol. Other Protocols, Policies and Coverage Determination Guidelines may 

apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Protocols, Policies and 

Guidelines as necessary. This protocol is provided for informational purposes. It does not constitute 

medical advice. 

COMMERCIAL INDICATIONS FOR COVERAGE 

Required Documentation: 

The decision regarding whether the requested procedure will be covered as reconstructive or excluded 

from coverage as cosmetic will require review of ALL of the following required clinical 

information/documentation: 

A. Contemporaneous physician office notes with the history of the medical condition(s) 

requiring treatment or surgical intervention. This documentation must include ALL of 

the following: 

1. The patient has venous insufficiency and valvular reflux that is consistent with 

the nature of the complaint that results in a functional deficit that is recurrent 

or persistent in nature AND 

2. The condition is causing the functional impairment (include the nature of the 

impairment) 

Varicose Vein Procedures Page 1 of 16

B. A written report, signed by the physician who interpreted the duplex ultrasonography 

with the patient in a standing or reverse Trendelenburg position that demonstrates 

reflux, duration of reflux and documentation of vein size. Hand-held ultrasound is 

insufficient for these purposes. 

C. For those members with pain and discomfort as their only complaint, a completed 

questionnaire addressing the degree and severity of the pain (refer to page 15 for a copy 

of the questionnaire) 

D. Documentation in physician office notes of skin changes, dermatitis, or ulceration of 

veins that account for the functional impairment. 

E. Treatment plan that must include proposed procedures and the expected outcome for the 

improvement of the functional deficit. 

ADDITIONAL INFORMATION: All required documentation must be submitted and approved 

through the standard precertification process. 

Criteria for a Coverage Determination as Reconstructive: 

REVIEW NOTE: Each of the requested surgical excisions or catheter entry points should be reviewed 

independently for coverage. 

A. Varicose vein ablation (surgical excision, radiofrequency ablation or endovenous laser ablation) of 

the great saphenous vein, small saphenous vein or principle branches (posterior accessory vein, 

anterior accessory vein and the cephalad extension of the small saphenous vein (vein of Giacomini)) is 

considered reconstructive when ALL of the following criteria are present: 

1. Condition is caused by venous insufficiency. 

2. Vein size by ultrasound 

a. If the planned ablation involves the great saphenous vein, the vein must be 5.5 mm or 

greater in diameter, as measured by duplex ultrasonography 

b. If the planned ablation involves the small saphenous vein, the vein must measure 5 mm 

or greater just below the saphenopopliteal junction. 

c. If the planned ablation involves the named principle branches, the vein must measure 5 

mm or greater. 

d. If there is either bleeding or ulceration from the varicose vein in question that has 

moderate or severe reflux as noted below, the vein sizes of lower diameters will be 

accepted. 

3. Documentation in a signed report of duration of reflux, as measured by duplex 

ultrasonography, in the standing or reverse Trendelenburg position that meets the following 

parameters: 

a. Greater than or equal to 500 milliseconds (ms) for the great saphenous, small saphenous 

or principle branches. 

b. Perforating veins > 350 ms 

c. Some duplex ultrasound readings will describe this as moderate to severe reflux which 

will be acceptable. 

4. Member must have one of the following functional impairments: 

a. Skin ulceration OR 


. Documented episode(s) of frank bleeding of the varicose vein due to erosion of or 

trauma to the skin OR 

c. Documented history of superficial thrombophlebitis OR 

d. Documented venous stasis dermatitis OR 

e. Moderate or severe pain and/or limitation of activities as indicated by answers to the 

following questions (the following questions are applicable to 4e only): 

B. Ablation of perforator veins is considered reconstructive when the following criteria are 

present: 

1. Evidence of perforator venous insufficiency measured by duplex 

ultrasonography report (see criteria above) and 

2. Perforator vein size is 3.5mm or greater and 

3. Documentation in office notes of venous stasis ulceration(s) due to the 

insufficiency. 

C. Endovenous ablation (radiofrequency or laser) of either reticular or telangiectatic veins is not 

considered reconstructive. 

High Ligation Procedures: 

For Commercial members, services can only be performed by surgeons and radiologists. 

Ligation of the greater saphenous vein at the saphenofemoral junction, as a stand-alone procedure, is 

not medically necessary for treating venous reflux. Ligation performed without stripping or ablation 

is associated with high long-term recurrence rates due to neovascularization. 

Ligation of the small saphenous vein at the saphenopopliteal junction, as a stand-alone procedure, is 

not medically necessary for treating venous reflux. Ligation performed without stripping or ablation 

is associated with high long-term recurrence rates due to increased risk of neovascularization. 

Ligation at the saphenofemoral junction, as a stand-alone procedure, is medically necessary, when 

used in patients with ascending superficial thrombophlebitis, to prevent the propagation of an active 

clot from the superficial system to the deep venous system. 

Ligation at the saphenofemoral junction, as an adjunct to radiofrequency ablation or endovenous 

laser ablation of the main saphenous veins, is not medically necessary. 

Policy History Revision Information 

Published clinical evidence has not demonstrated that the addition of saphenofemoral ligation to 

endovenous ablation procedures provides an additive benefit in resolving venous reflux or preventing 

varicose vein recurrence. Endovenous ablation is a clinically effective therapy for treating venous 

reflux. Adding ligation to the procedure adds clinical risk without adding clinical benefit. 

ADDITIONAL INFORMATION: 

Please refer to: 

• The enrollee’s COC or specific plan documents, 


• Coverage Determination Guideline, if one, for specific requirements for Reconstructive criteria 

MEDICARE & MEDICAID COVERAGE RATIONALE 

Medicare does not have a National Coverage Determination for Varicose Vein Procedures. 

There is a Local Coverage Determination for Nevada for Treatment of Varicose Veins of the Lower 

Extremity. The Local Coverage Determination is as follows: 

Indications and Limitations of Coverage and/or Medical Necessity 

Abstract 

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 (telangiectases) are dilated capillary veins that are most often treated 

for cosmetic purposes. Treatment of telangiectases (36468) is not covered by Medicare. 

Ligation and stripping of varicose veins is a treatment option that aims to eliminate reflux at the 

saphenofemoral junction. Some consider this the treatment of choice for moderate to large 

symptomatic varicose veins, ligation and stripping of the saphenous vein, has the lowest failure rate. 

Sclerotherapy, injecting sclerosing solutions directly into the abnormal veins, is an alternative 

occasionally selected for the treatment of varicose veins without significant saphenofemoral or 

saphenopopliteal incompetence. However, it is not considered to be as reliable and effective as surgical 

ligation and stripping. 

Sclerotherapy for cosmetic purposes is not considered medically necessary. Sclerotherapy is 

considered medically necessary for the treatment of small to medium sized vessels (generally less 

than 4 mm in diameter.) Sclerotherapy is not considered medically necessary for vessels larger than 5 

mm in diameter. 

Foam sclerotherapy of the saphenous vein at its junction with the deep venous system has been 

proposed as an alternative to ligation or saphenectomy, but its efficacy lacks significant scientific 

evidence to support its widespread use. 

Sclerotherapy of the saphenous vein at its junction with the deep system is not a covered procedure. 

Non-compressive sclerotherapy involves injection of a sclerosant into a vein without the application 

of a compressive dressing. Because it is not effective in producing long-term obliteration of the 

incompetent veins, noncompressive sclerotherapy is not covered by Medicare. 

Compressive sclerotherapy is the 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. Compressive sclerotherapy is 

indicated for local small to medium symptomatic varices, isolated incompetent perforators, or 


ecurrence of symptomatic varices after adequate surgical removal of varices. It is not considered an 

appropriate option for large, extensive or truncal varicosities. 

High ligation and compression sclerotherapy refers to ligation of a truncal junction (saphenofemoral 

or saphenopopliteal) followed by compressive sclerotherapy of one or more veins. 

Endovenous radiofrequency ablation (ERFA) and laser ablation are minimally invasive 

alternatives to vein ligation and stripping. Endovenous radiofrequency ablation is FDA-approved for 

treatment of the greater saphenous vein, perforators and tributary veins. Endovenous laser ablation is 

FDA-approved for the treatment of varicose veins and varicosities associated with superficial reflux of 

the greater saphenous vein. 

Stab phlebectomy or ambulatory phlebectomy may be considered medically necessary for 

treatment of patients who meet the medical necessity criteria listed below for varicose vein treatment 

whose symptoms and functional problems are attributable only to the secondary smaller vessels. Stab 

phlebectomy of the same vein performed on the same day as endovenous radiofrequency or laser 

ablation may be covered if the criteria for reasonable and necessary service are met and 

documentation in the chart supports the medical necessity. 

Indications: 

Medicare will consider interventional treatment of varicose veins (sclerotherapy, ligation with or 

without stripping, and endovenous radiofrequency or laser ablation) medically necessary if the patient 

remains symptomatic after a 6-8 week trial of conservative therapy. Based on recent literature 

combination therapy (the use of compression and surgery) has been shown to decrease 12 month ulcer 

recurrence rates and therefore may be considered in patients with chronic venous ulcers. Components 

of the conservative therapy include, but are not limited to: 

weight reduction, 

a daily exercise plan, 

periodic leg elevation, and 

the use of graduated compression stockings. 

The conservative therapy must be documented in the medical record. Conservative treatment may slow 

down progression of disease or may demonstrate (if symptoms reduced) that treating the disease may 

eliminate the symptoms. 

The patient is considered symptomatic if any of the following signs and symptoms of significantly 

diseased vessels of the lower extremities are documented in the medical record: 

stasis ulcer of the lower leg, as above, 

significant pain and/or significant edema that interferes with activities of daily living, 

bleeding associated with the diseased vessels of the lower extremities, 

recurrent episodes of superficial phlebitis, 

stasis dermatitis, or 

refractory dependent edema. 

Additional indications and limitations are discussed according to type of treatment. 


In addition to the requirement for failure of a 6-8 week trial of conservative treatment and the 

symptoms described above, coverage of endovenous ablation therapy is limited to patients with: 

laser ablation of veins with a vein diameter less than or equal to 20mm, or 

ERFA for a vein diameter less than or equal to 12mm, or 

absence of thrombosis or vein tortuosity, which would impair catheter advancement, and 

absence of significant peripheral artery disease. 

Radiofrequency/laser ablation is covered only for treatment of the lesser or greater saphenous veins 

and selected tributaries to improve symptoms attributable to saphenofemoral or saphenopopliteal 

reflux. Coverage is only for FDA devices specifically approved for these procedures. 

Limitations: 

Duplex ultrasound is often used in conjunction with other non-invasive physiologic testing to define 

the anatomy and physiology of the varicose vein network prior to injection or surgical intervention. 

There is adequate evidence that the pre-procedural ultrasound is helpful, and Medicare will cover a 

pre-procedure Duplex scan (93970 or 93971) used in conjunction with other non-invasive physiologic 

testing (93965) to determine the extent and configuration of the varicosities. This A/B MAC expects 

that these studies will be performed by the provider planning to provide the therapy. This A/B MAC 

will allow this study once per provider or provider group. Clinical experience supports the use of 

ultrasound during the sclerotherapy procedure, and evidence shows that the outcomes may be 

improved and complication rates may be minimized when ultrasound guidance is used. 

Medicare will cover intraoperative ultrasonic guidance in situations when it is medically necessary. 

Medicare includes payment for the intraoperative ultrasound in the payment for the ERFA and laser 

ablation procedures. 

A postoperative ultrasound will be covered if the test is reasonable and necessary for the diagnosis and 

treatment of a complication. 

Cosmetic surgery is statutorily excluded from coverage by Medicare. The following interventional 

treatments are considered to be cosmetic and are denied as not medically necessary: 

Interventional treatment of asymptomatic varicosities. 

Treatment of telangiectases (36468). 

Sclerotherapy for cosmetic purposes. 

Medicare cannot cover services which are not reasonable and necessary for the treatment of illness 

or injury or to improve the functioning of a malformed body member. The following interventional 

treatments are not considered medically reasonable or necessary and are denied as such: 

Interventional treatment of symptomatic varicosities without documentation of a failed 6-8 

week trial of conservative therapy in patients without chronic venous ulcers. 

Sclerotherapy for vessels larger than 5 mm in diameter. 

Reinjection following recanalization or failure of vein closure without recurrent signs or 

symptoms. 

Sclerotherapy of the saphenous vein at its junction with the deep venous system. 


Noncompressive sclerotherapy. 

Compressive sclerotherapy for large, extensive or truncal varicosities. 

Sclerotherapy, ligation and/or stripping of varicose veins, or endovenous ablation therapy are 

not covered for pregnant women, patients on anticoagulant therapy, or patients with the 

inability to tolerate compressive bandages or stockings; severe distal arterial occlusive disease; 

obliteration of deep venous system; an allergy to the sclerosant; or a hypercoaguable state. 

Any interventional treatment that uses equipment not approved for such purposes by the FDA. 

Laser ablation of veins with a diameter less than or equal to 20mm and ERFA for vein diameter 

less than or equal to 12mm. 

Endovenous ablation therapy in the presence of thrombosis or venous tortuosity which would 

impair catheter advancement. 

Documentation Requirements 

The patient's medical record must contain documentation that fully supports the medical necessity for 

services included within this LCD. This documentation includes, but is not limited to, relevant medical 

history, physical examination, and results of pertinent diagnostic tests or procedures. 

The patient's medical record must document the following: 

history and physical findings supporting a diagnosis of symptomatic varicose veins 

failure of an adequate trial of conservative treatment as described in the "Indications" section of 

this LCD 

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 

and 

necessity of utilizing ultrasound guidance, if used. 

The medical record must also include pre-treatment photographs of the varicose veins for which claims 

for sclerotherapy are submitted to Medicare. These photographs must be made available to the A/B 

MAC upon request for review. 

Utilization Guidelines 

Coverage for podiatrists is limited by scope of practice specific to the state in which the service is 

provided. 

Medicare recognizes that multiple injections are needed to perform sclerotherapy and that responses 

differ due to the anatomical site being treated. Medicare would not expect to see the following when 

performing sclerotherapy: 

 

 

More than three sclerotherapy sessions for each leg. 

Only one sclerotherapy service per treatment session should be reported for either leg, 

regardless of how many veins are treated per session. 

Patients are not expected to require ablation of the saphenous vein by radiofrequency or laser more 


than once for either leg. 

A duplex ultrasound examination will be allowed when performed within 1 week (preferably within 72 

hours) of ERFA to check for any evidence of thrombus extension from the saphenofemoral junction 

into the deep system. 

For Medicare and Medicaid Determinations Related to States Outside of Nevada: 

Please review Local Coverage Determinations that apply to other states outside of Nevada. 

http://www.cms.hhs.gov/mcd/search 

Important Note: Please also review local carrier Web sites in addition to the Medicare Coverage 

database on the Centers for Medicare and Medicaid Services’ Website. 

BACKGROUND 

Varicose veins are enlarged veins that are swollen and raised above the surface of the skin. They can 

be dark purple or blue, and look twisted and bulging. Varicose veins are commonly found on the backs 

of the calves or on the inside of the leg. Veins have one-way valves that help keep blood flowing 

towards the heart. When the valves become weak or damaged and do not close properly, blood can 

back up and pool in the veins causing them to get larger. The resulting condition is known as venous 

insufficiency or venous reflux. Varicose veins may lead to complications such as pain, blood clots or 

skin ulcers. 

Varicose veins are treated with lifestyle changes and medical procedures done either to remove the 

veins or to close them. Sclerotherapy uses a liquid chemical to close off a varicose vein. Endovenous 

ablation therapy uses lasers or radiofrequency energy to create heat to close off a varicose vein. Vein 

stripping and ligation involves tying shut and removing the veins through small cuts in the skin 

(National Heart, Lung and Blood Institute 2009). 

CLINICAL EVIDENCE 

O’Hare et al. (2008) conducted a multicenter, prospective cohort study of patients undergoing small 

saphenous vein surgery (SSV). Patients were evaluated at six weeks and one year after surgery. A 

total of 204 legs were reviewed at one year; 67 had small saphenous varicose vein stripping, 116 had 

saphenopopliteal junction (SPJ) disconnection only and the remainder had miscellaneous procedures. 

The incidence of visible recurrent varicosities at one year was lower after SSV stripping than after 

disconnection only, although this did not reach statistical significance. The rate of SPJ incompetence 

detected by duplex at one year was significantly lower in patients who underwent SSV stripping than 

in those who did not. 

In a literature review of long-term results following high ligation supplemented by sclerotherapy, 

Recek (2004) found that ligation of the saphenofemoral junction alone provokes a higher recurrence 

rate in comparison with high ligation and stripping. The hemodynamic improvement achieved 


immediately after high ligation deteriorates progressively during the follow-up owing to recurrent 

reflux. 

Winterborn et al. (2004) conducted an 11 year follow-up study on the Jones et al. patient group. A 

cumulative total of 83 legs had developed clinically recurrent varicose veins by 11 years (62%). There 

was no statistically significant difference between the ligation-only and the stripping groups. 

Reoperation was required for 20 of 69 legs that underwent ligation alone compared with 7 of 64 legs 

that had additional long saphenous vein stripping. Freedom from reoperation at 11 years was 70% after 

ligation, compared with 86% after stripping. The presence of neovascularization, an incompetent 

superficial vessel in the thigh or an incompetent saphenofemoral junction on duplex imaging at 2 years 

postoperatively increased the risk of a patient's developing clinically recurrent veins. Results from the 

study indicate that stripping the long saphenous vein is recommended as part of routine varicose vein 

surgery as it reduces the risk of reoperation after 11 years, although it did not reduce the rate of visible 

recurrent veins. 

Dwerryhouse et al. (1999) designed as a 5-year follow-up study on the Jones et al. patient group. 78 

patients (110 legs) underwent clinical review and duplex scan imaging. Sixty-five patients remained 

pleased with the results of their surgery (35 of 39 stripped vs. 30 of 39 ligated). Reoperation for 

recurrence was necessary for three of 52 of the legs that underwent stripping vs. 12 of 58 ligated legs. 

Neovascularization at the saphenofemoral junction was responsible for 10 of 12 recurrent veins that 

underwent reoperation and also was the cause of recurrent saphenofemoral incompetence in 12 of 52 

stripped veins vs. 30 of 58 ligated legs. The authors concluded that stripping reduced the risk of 

reoperation by two thirds after 5 years and should be routine for primary long saphenous varicose 

veins. 

Jones et al. (1996) conducted a randomized controlled trial of one hundred patients (133 legs) to 

determine whether routine stripping of the long saphenous vein reduced recurrence after varicose vein 

surgery. A two year follow-up in 81 patients (113 legs) showed that 89% of patients remained satisfied 

with the results of their surgery, though 35% had recurrent veins on clinical examination. Recurrence 

was reduced in patients who had their long saphenous vein stripped. Neovascularization was detected 

in 52% of limbs and was the most common cause of recurrence. 

Rutgers et al. (1994) conducted a prospective randomized study comparing stripping and local 

avulsions with high ligation of the saphenofemoral junction combined with sclerotherapy for the 

treatment of greater saphenous vein insufficiency. Of 156 consecutive patients, 89 legs were randomly 

allocated to stripping and 92 to high ligation. Patients were followed-up at 3 months and 1, 2, and 3 

years after treatment. At 3 years, 69 limbs in the stripping group (78%) and 73 limbs in the ligation 

group (79%) were available to follow-up. The authors found that clinical and Doppler ultrasound 

evidence of reverse flow in the saphenous vein was significantly less after stripping. 

Eighty-nine legs with long saphenous vein (LSV) reflux and saphenofemoral junction incompetence 

were treated by saphenofemoral ligation and multiple avulsions. Patients were randomized to undergo 

additional stripping of the LSV (n = 43) or no additional treatment (n = 46). At a median of 21 months 

after surgery, more patients were free of recurrence when the LSV had been stripped compared with 

saphenofemoral ligation alone. The authors concluded that the addition of LSV stripping to 

saphenofemoral ligation and multiple avulsions results in a better overall outcome (Sarin, 1994). 


During endovenous ablation procedures, radiofrequency or laser energy is applied to heat the vein, 

causing the vessel to close and eventually be absorbed by the body. This technique achieves the same 

effect as saphenofemoral or saphenopopliteal ligation and stripping. Adding ligation of the main trunk 

to the procedure has not been shown to provide an additive benefit in resolving venous reflux or 

preventing varicose vein recurrence. 

In a systematic review, Darwood and Gough found that adjunctive saphenofemoral ligation is not 

necessary to achieve success with endovenous laser therapy of the greater saphenous vein (Darwood, 

2009). Similarly, a randomized controlled trial conducted by Disselhoff et al. (2008) found that the 

addition of saphenofemoral ligation to endovenous ablation made no difference to the short-term 

outcome of varicose vein treatment. Further studies with larger patient populations are needed to 

establish the superiority of adjunctive saphenofemoral ligation in improving long-term outcomes. 

Theivacumar et al. (2007) also found that saphenofemoral ligation following endovenous laser ablation 

was unnecessary. Persistent non-refluxing greater saphenous vein tributaries at the saphenofemoral 

junction did not have an adverse impact on clinical outcome 1 year after successful endovenous laser 

ablation of the greater saphenous vein. 

Professional Societies 

No specialty society recommendations related to the policy were identified at this time. 

U.S. FOOD AND DRUG ADMINISTRATION (FDA) 

Vein ligation surgery is a procedure and therefore not subject to FDA regulation. 

APPLICABLE CODES FOR COMMERCIAL COVERAGE 

The codes listed in this policy are for reference purposes only. Listing of a service or device code in 

this policy does not imply that the service described by this code is a covered or non-covered health 

service. Coverage is determined by the benefit document. This list of codes may not be all inclusive. 

CPT ® Codes for Vein 

Procedures 

36475 

36476 

Description 

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all 

imaging guidance and monitoring, percutaneous, radiofrequency; first vein 

treated 


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) 

36478 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all 

imaging guidance and monitoring, percutaneous, laser; first vein treated 

36479 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all 


37700 

imaging guidance and monitoring, percutaneous, laser; second and 



Ligation and division of long saphenous vein at saphenofemoral junction, or 

distal interruptions 

37718 Ligation, division, and stripping, short saphenous vein 

37722 Ligation, division, and stripping, long (greater) saphenous veins from 

saphenofemoral junction to knee or below 

Ligation and division of short saphenous vein at saphenopopliteal junction 

37780 

(separate procedure). 

CPT ® is a registered trademark of the American Medical Association. 

NOTE: CPT Code 37799 should be used to report “Trivex Procedure” 

APPLICABLE CODES FOR MEDICARE & MEDICAID COVERAGE 

The codes listed in this policy are for reference purposes only. Listing of a service or device code in 

this policy does not imply that the service described by this code is a covered or non-covered health 

service. Coverage is determined by the benefit document. This list of codes may not be all inclusive. 

CPT ® Codes for Vein Description 

Procedures 

36470 Injection of sclerosing solution; single vein 

36471 Injection of sclerosing solution; multiple veins, same leg 


36475 imaging guidance and monitoring, percutaneous, radiofrequency; first vein 

treated 


imaging guidance and monitoring, percutaneous, radiofrequency; second and 

36476 




36478 

imaging guidance and monitoring, percutaneous, laser; first vein treated 


imaging guidance and monitoring, percutaneous, laser; second and 

36479 



Ligation and division of long saphenous vein at saphenofemoral junction, or 

37700 

distal interruptions 

37718 Ligation, division, and stripping, short saphenous vein 

Ligation, division, and stripping, long (greater) saphenous veins from 

37722 

saphenofemoral junction to knee or below 


37735 

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 

37760 

Ligation of perforator veins, subfacsial, radical (linton type), including skin 

graft, when performed, open, 1 leg 

37761 

Ligation of perforator vein(s). subfascial, open, including ultrasound 

guidance, when performed, 1 leg 

37765 Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions 

37766 Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions 

37780 

Ligation and division of short saphenous vein at saphenopopliteal junction 

(separate procedure) 

37785 Ligation; division, and/or excision of varicose vein cluster(s), 1 leg 

37799 Unlisted procedure, vascular surgery 

76942 

Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, 

localization device), imaging supervision and interpretation 

Noninvasive physiologic studies of extremity veins, complete bilateral study 

93965 (e.g., Doppler waveform analysis with responses to compression and other 

maneuvers, phleborheography, impedance plethysmography) 

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 

CPT ® is a registered trademark of the American Medical Association. 

NOTE: CPT Code 37799 should be used to report “Trivex Procedure” 

ICD-9 Codes That Description 

Support Medical 

Necessity 

451.0 Phlebitis and thrombophlebitis of superficial vessels of lower extremities 

451.11 Phlebitis and thrombophlebitis of femoral vein (deep) (superficial) 

451.2 Phlebitis and thrombophlebitis of lower extremities, unspecified 

459.10 Postphlebitic syndrome without complications 

459.11 Postphlebitic syndrome with ulcer 

459.12 Postphlebitic syndrome with inflammation 

459.13 Postphlebitic syndrome with ulcer and inflammation 

459.19 Postphlebitic syndrome with other complication 

459.31 Chronic venous hypertension with ulcer 

459.32 Chronic venous hypertension with inflammation 

459.33 Chronic venous hypertension with ulcer and inflammation 


ICD-9 Codes that DO Description 

NOT Support 

Medical Necessity 

448.0 Hereditary hemorrhagic telangiectasia (spider veins) 

448.1 Nevus non-neoplastic 

448.9 Other and unspecified capillary diseases 

454.0 Varicose veins of lower extremities with ulcer 

454.1 Varicose veins of lower extremities with inflammation 

454.2 Varicose veins of lower extremities with ulcer and inflammation 

454.8 Varicose veins of the lower extremities with other complications 

459.81 Unspecified venous (peripheral) insufficiency 

NOTE: CPT codes 36470, 36471, 36475, 36476, 36478, 36479, 37700, 37718, 37722, 37735, 37760, 37761, 

37765, 37766, 37780, 37785 and 37799 (when used to report "Trivex Procedure"), submitted for any of the 

previous three ICD-9-CM codes will be denied for lack of medical necessity: 

REFERENCES 

Allan PL. Role of ultrasound in the assessment of chronic venous insufficiency. Ultrasound Q. 2001 

Mar;17(1):3-10. 

Darwood RJ, Gough MJ. Endovenous laser treatment for uncomplicated varicose veins. Phlebology. 

2009;24 Suppl 1:50-61. 

Disselhoff BC, der Kinderen DJ, Kelder JC, Moll FL. Randomized clinical trial comparing 

endovenous laser ablation of the great saphenous vein with and without ligation of the saphenofemoral 

junction: 2-year results. Eur J Vasc Endovasc Surg. 2008 Dec;36(6):713-8. 

Dwerryhouse S, Davies B, Harradine K, Earnshaw JJ. Stripping the long saphenous vein reduces the 

rate of reoperation for recurrent varicose veins: five-year results of a randomized trial. J Vasc Surg. 

1999 Apr;29(4):589-92. 

ECRI. Health Technology Assessment Information Service (HTAIS) Custom Hotline Report. Surgical 

Ligation and Stripping of Varicose Veins. July 2004. 

Eklof B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classification of chronic venous 

disorders: Consensus statement. Journal of Vascular Surgery. 2004; 40:1248-1252. 

Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL). 2007 ICAVL 

Standards. Part II: Vascular Laboratory Operations – Peripheral Venous. Available at: 

http://www.icavl.org/icavl/pdfs/venous2007.pdf 

Jones L, Braithwaite BD, Selwyn D, et al. Neovascularisation is the principal cause of varicose vein 

recurrence: results of a randomised trial of stripping the long saphenous vein. Eur J Vasc Endovasc 

Surg. 1996 Nov;12(4):442-5. 


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QUESTIONNAIRE 

QUESTIONNAIRE 

1) Do the patient’s daily activities require prolonged periods of standing? 

If yes, what activity requires prolonged periods of standing? 

_______________________________________________________________________ 

If yes, how many times during the day does the patient have to sit or take a break due to 

aching, cramping, burning, itching or swelling in the lower extremities? 

Never (0) Once per day (1) 2 – 3 times per day (2) 4 or more times per day (3) 

2) Does the patient take over-the-counter medications (e.g., aspirin, ibuprofen, other NSAIDS or a 

similar type of medication) or prescription medications for aching, cramping, burning or swelling of the 

lower extremities? 

If yes, what is the medication and dosage? 

_______________________________________________________________________ 

If yes, how many days in a two week period of time did the patient take the medication? 

0 - 2 days (0) 3 - 4 days (1) 5 - 6 days (2) 7 or more days (3) 

Scale: 

0 =no symptoms 

1=mild 

2=moderate 

3=severe 

(If the member has a moderate or severe rating for either question #1 or question #2, he/she would 

meet the criteria) 


PROTOCOL HISTORY/REVISION INFORMATION 

Date 

07/28/2011 

03/24/2011 

01/28/2011 

11/2010 

07/13/2010 

04/23/2010 

07/24/2009 

Action/Description 

Corporate Medical Affairs Committee 

The foregoing Health Plan of Nevada/Sierra Health & Life Operations protocol has been adopted from 

an existing UnitedHealthcare coverage determination guideline that was researched, developed and 

approved by the UnitedHealthcare Coverage Determination Committee.

VARICOSE VEIN PROCEDURES - Health Plan of Nevada

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