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Medical Policy: 02.01.26
Original Effective Date: July 1994
Reviewed: April 2011
Revised: October 2003
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
The venous system of the lower limbs consists of two channels, a deep channel (popliteal and femoral veins) that runs within the muscular system and a superficial channel (greater and lesser saphenous veins) that runs within the skin and the subcutaneous tissues and connects with deeper channels by epifascial perforating veins.
The term varicose vein is used to designate enlarged tortuous veins that are often associated with abnormal valvular function. Varicose veins of the superficial system are typically secondary to valve incompetence. The term telangiectasis (spider veins) is used to designate smaller, visible blood vessels that are permanently dilated.
Several treatments are available depending upon the pathology in the venous system.
- Compressive therapy, e.g. bandages, compression stockings
- Sclerotherapy
- Echo sclerotherapy or ultrasound guided sclerotherapy
- Stripping and ligation
- Endoluminal radiofrequency ablation
- Endovenous laser treatment
- Transilluminated Powered Phlebectomy (TIPP) (TriVex™ System). This is a minimally invasive technique to remove superficial varicosities.
Sclerotherapy, stripping and ligation and compressive therapy are conventional treatments.
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Prior Approval:
Not applicable
However, services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial may result if criteria are not met.
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Policy:
The following treatments for varicose veins may be considered medically necessary:
- Compressive therapy
- Stripping, ligation and division
- Endovenous laser treatment and endoluminal radiofrequency ablation of the greater saphenous vein, as an alternative to saphenous vein ligation and stripping in patients with documented symptomatic saphenofemoral reflux. NOTE: Reflux demonstrated by hand-held Doppler should be confirmed by duplex studies.
- Sclerotherapy and Transilluminated Powered Phlebectomy (TIPP) (TriVex™ System) may be considered medically necessary if any two or more of the following criteria are met:
- Symptomatic varicosities which would otherwise warrant ligation
- Intractable pain
- An episode of phlebitis
- Anatomic derangement beyond simple cosmetic derangement
- Varicose veins are not treatable or have failed treatment with conservative measures such as prescribed pressure gradient stockings.
Telangiectasis (spider vein) treatment is considered cosmetic and, therefore, a contract exclusion.
Echo sclerotherapy is considered investigational.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 37700 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
- 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, subfascial, 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
- 36468 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk
- 36469 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia) face
- 36470 Injection of sclerosing solution; single vein
- 36471 Injection of sclerosing solution; multiple veins, same leg
- 36475 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated
- 36476 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all 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 imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)
- S2202 Echosclerotherapy
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Selected References:
- Guideline/outcome committee, Task Force. Guidelines of care for sclerotherapy treatment of varicose and telangiectatic leg veins. Journal of the American Academy of Dermatology 1996;34(3):523-528.
- Dover JS, Sadick NS, Goldman MP. The role of lasers and light sources in the treatment of leg veins. Dermatologic Surgery1999;25:4:328-336.
- Kauvar ANB. The role of lasers in the treatment of leg veins. Seminars in Cutaneous Medicine and Surgery 2000;19:4:245-252.
- Marley WM, Marley NF. Sclerotherapy treatment of varicose veins. Seminars in Dermatology1993;12:2:98-101.
- Bergan JJ. Varicose Veins: Hooks, clamps, and suction. Application of new technique to enhance varicose vein surgery. Seminars in Vascular Surgery 2002;15(1):21-26.
- Cheshire N, et al. Powered Phlebectomy (TriVex™) in Treatment of Varicose Veins. Annals of Vascular Surgery 2002;16:488-494.
- Arumugasamy M, McGreal G, O’Connor A, Kelly C, Bouchier-Hayes D, Leahy A. The technique of transilluminated powered phlebectomy-A novel minimally invasive system for varicose vein surgery. European Journal of Vascular and Endovascular Surgery 2002;23:180-182.
- Min RJ, Bavarro L. Transcatheter duplex ultrasound-guided sclerotherapy for treatment of greater saphenous vein reflux: Preliminary report. Dermatology Surgery 2000;26:410-414.
- Guex JJ, Isaacs MN. Comparison of surgery and ultrasound guided sclerotherapy for treatment of saphenous varicose veins: must the criteria for the assessment be the same? International Angiology 2000;19(4):299-302.
- Kanter A. Clinical determinants of ultrasound-guided sclerotherapy outcome. Part I: the effect of age, gender and vein size. American Society for Dermatology Surgery, Inc. Dermatology Surgery 1998;24:131-135.
- Kanter A. Clinical determinants of ultrasound-guided sclerotherapy: Part II in search of the ideal Injectate volume. American Society for Dermatology Surgery, Inc. Dermatology Surgery 1998; 24:136-140.
- Rabe, E, Otto, J, Schliephake, D, and Pannier, F. Efficacy and safety of great saphenous vein sclerotherapy using standardised polidocanol foam (ESAF): a randomised controlled multicentre clinical trial. Eur J Vasc Endovasc Surg. 2008;35(2):238-245.
- Hamel-Desnos, C, Ouvry, P, Benigni, JP et al. Comparison of 1% and 3% polidocanol foam in ultrasound guided sclerotherapy of the great saphenous vein: a randomised, double-blind trial with 2 year-follow-up. "The 3/1 Study". Eur J Vasc Endovasc Surg. 2007;34(6):723-729.
- Luebke, T, Gawenda, M, Heckenkamp, J, and Brunkwall, J. Meta-analysis of endovenous radiofrequency obliteration of the great saphenous vein in primary varicosis. J Endovasc Ther. 2008;15(2):213-223.
- Luebke, T, Brunkwall, J. Systematic review and meta-analysis of endovenous radiofrequency obliteration, endovenous laser therapy, and foam sclerotherapy for primary varicosis. J Cardiovasc Surg (Torino). 2008;49(2):213-233.
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Policy History:
Date Reason Action
April 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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