anatomically related persistent junctional reflux is demonstrated after the great or small saphenous veins have been removed or ablated.who are being treated or have previously been treated by one of the procedures listed above for incompetence (i.e., reflux) at the saphenofemoral junction or saphenopopliteal junction and.See Appendix.Įndovenous ablation procedures are considered medically necessary adjunctive treatment of symptomatic accessory saphenous veins for persons who meet medical necessity criteria for endovenous ablation above and Perforating vein is located underneath an active or healed venous stasis ulcer (also known as CEAP C5 or C6).Outward flow duration of 500 msec duration or more and.Perforating vein diameter measured by recent ultrasound of 3.5 mm or greater and.Surgical ligation (including subfascial endoscopic perforator vein surgery (SEPS)) or endovenous ablation procedures are considered medically necessary for the treatment of incompetent perforating veins when all of the following are met: Severe and persistent pain and swelling interfering with activities of daily living.įootnote1* Note: A trial of conservative management is not required for persons with persistent or recurrent varicosities who have undergone prior endovenous catheter ablation procedures or stripping/division/ligation in the same leg because conservative management is unlikely to be successful in this situation.Recurrent superficial thrombophlebitis or.Saphenous varicosities result in either of the following, and symptoms persist despite a 3-month trial of conservative management Footnote1* (including prescription gradient support compression stockings).More than 1 episode of minor hemorrhage from a ruptured superficial varicosity or a single significant hemorrhage from a ruptured superficial varicosity, especially if transfusion of blood is required or.Intractable ulceration secondary to venous stasis or.Saphenous varicosities result in any of the following:.Vein size is 4.5 mm or greater in diameter measured by ultrasound below the saphenofemoral or saphenopopliteal junction (not valve diameter at junction) and.Ultrasound documented junctional reflux duration of 500 milliseconds (ms) or greater in the saphenofemoral or saphenopopliteal vein to be treated and.Incompetence at the saphenofemoral junction or saphenopopliteal junction is documented by recent (performed within the past 6 months) Doppler or duplex ultrasound scanning, and all of the following criteria are met: Endovenous laser ablation of the saphenous vein (ELAS) (also known as endovenous laser treatment (EVLT)).Radiofrequency endovenous occlusion (VNUS procedure) and.Great saphenous vein or small saphenous vein ligation / division / stripping. ![]() This Clinical Policy Bulletin addresses treatment of varicose veins.Īetna considers the following procedures medically necessary for treatment of varicose veins: ![]() Number: 0050 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
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