Varicose Veins Treatment - PDF Document

Presentation Transcript

  1. Varicose Veins Treatment I.Policy University Health Alliance (UHA) will reimburse for treatment of primary venous insufficiency manifested by varicose vein disease when determined to be medically necessary and within the medical criteria guidelines (subject to limitations and exclusions) indicated below. II.Criteria/Guidelines A.Surgical treatment for primary venous insufficiency manifested by varicose veins is covered (subject to Limitations/Exclusions and Administrative Guidelines) within the following parameters: 1.The patient is symptomatic. A patient is considered symptomatic if any of the following signs and symptoms is present and documented in the patient’s medical record. a.Significant pain and/or significant edema that interferes with activities of daily living b.Bleeding associated with the diseased vessels of the lower extremities c.Recurrent episodes of superficial phlebitis d.Stasis ulcer of the lower leg e.Stasis dermatitis f.Refractory dependent edema g.Symptoms which are supportive of the diagnosis of symptomatic varicose veins such as heaviness, fatigability, itching, tingling, throbbing, and burning in the affected extremity, and night cramps. These symptoms are associated with the erect position when the legs are dependent, they are often worse at the end of the day, and usually relieved by elevation of the legs. h.Additional value is attached to physical findings associated with C3-6 levels on CEAP scale to include swelling of the lower leg, ankle, or foot when associated with venous reflux, brownish pigmentation of the lower leg and ankle (gaiter area) associated with venous reflux, thickening of the skin and subcutaneous tissues (sclerosis) of the gaiter area, and ulceration of the skin of the lower leg and ankle associated with reflux. 2.Disease must be classified C3 or greater within the CEAP (Clinical, Etiology, Anatomy, Pathophysiology) classification system, graded as: C0- No clinical signs C1- Small varicose veins C2- Large varicose veins C3- Edema C4- Skin changes without ulceration C5- Skin changes with healed ulceration C6- Skin changes with active ulceration Varicose Veins Treatment Payment Policy Page 1

  2. 3.A trial of conservative therapy of eight weeks duration has been ineffective. Conservative therapy has included a trial of compression therapy. 4.Doppler ultrasound or duplex scan has verified reflux at the saphenofemoral or saphenopopliteal junction, reflux in incompetent perforator veins, or axial reflux in the great saphenous or collateral vein. C.The following types of surgery are covered for the conditions indicated, if criteria are met: 1.Ligation and stripping, endovenous radiofrequency, or laser ablation of the greater or lesser (small/short) saphenous veins in patients with saphenofemoral reflux or axial reflux of the great or lesser (small/short) saphenous veins. 2.Mechanicochemical ablation (e.g. Clarivein) of the greater or lesser (small/short) saphenous veins in patients with saphenofemoral reflux or axial reflux of the great or lesser (small/short) saphenous veins. 3.Endoluminal ablation in patients with greater saphenous vein reflux or small saphenous vein reflux as documented by Doppler ultrasonography. 4.Stab avulsion, hook phlebectomy, sclerotherapy or transilluminated powered phlebectomy as adjuvant treatment of symptomatic varicose veins concomitant with or after the underlying cause (reflux) is addressed. 5.Sclerotherapy as the sole treatment of varicose tributaries without associated ligation of the saphenofemoral junction and stripping of the saphenous vein when at least one of the following criteria is met and the supporting clinical documentation is submitted: a.There is need for preservation of the saphenous vein for possible bypass surgery in the future; b.The patient is very young and surgical removal will be premature; c.The patient is very old or medically fragile and surgical removal would be excessive; d.The patient is inactive and removal of the saphenous vein would serve no useful purpose; e.The patient is not in need of long-term control of venous reflux; such patients will include an older patient with recurrent bleeding from varicose blebs, or an older patient with recurrent thrombophlebitis in varicose tributaries. 6.Retrograde injections of the sclerosing solution after ligation of the saphenofemoral junction when upper thigh branches are thought to be a source of recurrent varicosities. 7.Sclerotherapy or ligation of incompetent perforators will be covered when duplex scanning verifies reflux of the vessels and symptomatic varicosities result. 8.Sclerotherapy of superficial telangiectasias also known as spider veins when they truly threaten to, or cause rupture with spontaneous bleeding. 9.Ablation of incompetent perforator veins by thermal, laser, or radiofrequency ablation may be covered on a case by case basis in patients with severe skin changes or ulceration caused by these perforators and who have been resistant to other forms of conservative treatment. III.Limitations/Exclusions A.Sclerotherapy of the greater saphenous vein, with or without associated ligation of the saphenofemoral junction, is not coveredbecause it is not known to improve health outcomes. B.Energy-based ablation of veins other than those listed in this policy are not coveredbecause they are not known to be effective in improving health outcomes. Varicose Veins Treatment Payment Policy Page 2

  3. C.Repeat sclerotherapy requires prior authorization and must include documentation of persistent functional complaints. D.If both lower extremities require treatment and this is not accomplished at one setting, payment will be denied in the absence of case specific and explicit documentation made available for UHA to conduct a retrospective review to show justification of staging. E.Indications or conditions not listed in this policy are considered cosmetic and are not covered. F.Post procedure ultrasound is covered only when there is documentation of a medically significant condition. Routine post procedure ultrasound is not covered. G.All covered procedures referenced in this policy are covered only when performed by a practioner with thetraining and experience to comprehensively manage complicated or difficult cases and the potential complications that can arise. Vascular surgeons are the best trained and most skilled to manage venous disease. In the absence of board certification in vascular surgery, UHA may request documentation supporting the mastery of such expertise. NOTE: This UHA payment policy is a guide to coverage, the need for prior authorization and other administrative directives. It is not meant to provide instruction in the practice of medicine and it should not deter a provider from expressing his/her judgment. Even though this payment policy may indicate that a particular service or supply is considered covered, specific provider contract terms and/or member’s individual benefit plans may apply, and this policy is not a guarantee of payment UHA reserves the right to apply this payment policy to all UHA companies and subsidiaries. UHA understands that opinions about and approaches to clinical problems may vary. Questions concerning medical necessity (see Hawaii Revised Statutes §432E-1.4) are welcome. A provider may request that UHA reconsider the application of the medical necessity criteria in light of any supporting documentation. IV.Administrative Guidelines A.Prior authorization is required. B.All of the following documentation must be submitted: 1.Imaging studies and photographs; 2.Clinical notes describing symptoms and physical findings; and 3.Documentation of failure of conservative treatment. C.Photographs of affected limbs must be dated and made available for review at UHA’s request. D.Duplex ultrasound studies must be dated, memorialized, and made available for review at UHA’s request. 1.The Duplex ultrasound report must document the following: a.Presence or absence of reflux in GSV, SSV, AASV, other longitudinal veins connecting upper thigh to lower leg. The extent of reflux in target vein should be specified as either segmental or axial. b.Connection of the vein intended to be treated to the symptomatic varicose veins, ulcer, or area of concern in the leg. c.Presence or absence of reflux in the perforator anatomically related to site of symptoms or ulceration. Varicose Veins Treatment Payment Policy Page 3

  4. d.Presence or absence of reflux in deep veins. If present, the reflux should be specified as segmental or axial. e.The cut-off criterion for pathological reflux should be specified. 2.Ultrasound images must meet these criteria: a.All relevant anatomical structures on the ultrasound images should be clearly labeled. The anatomical segment of the vein should be labeled (proximal, mid, distal thigh, etc.). b.The anatomical landmarks should be identifiable. For example, the SFJ image should include CFV; SPJ image should include the popliteal vein and (when possible) femur, tibia, or knee joint. Saphenous compartment (“saphenous eye”) should be visible on the transverse image of the GSV in proximal thigh. c.The ultrasound image should be oriented in a standard manner. Longitudinal images should be taken with proximal direction to the left, and distal to the right. The medial and lateral directions on the transverse images should be labeled. d.Spectral Doppler should be used for reflux identification; color Doppler images are not sufficient. All reflux measurements should be done in longitudinal (to the vein axis) position of the transducer. e.The sample volume should be seen and properly positioned on the b-mode part of the duplex image. The ultrasound beam should be at an acute angle to the axis of the vein, and the angle correction should be 60-degrees or less. f.Both outflow and reflux should be depicted on the image that documents the presence of reflux. E.Procedures performed over the course of more than one day/session must have clear documentation in the medical record for the specific reasons that each additional day/session is medically necessary. F.Prior Authorization is required for repeat sclerotherapy. Documentation of persistent functional complaints must be submitted. G.To request prior authorization, please submit via UHA’s online portal. If a login has not been established, you may contact UHA at 808-532-4000 to establish one. H.This policy may apply to the following codes. Inclusion of a code in the table below does not guarantee that it will be reimbursed. The following CPT codes require prior authorization. CPT Code 36468 36470 36471 Description Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk Injection of sclerosant; single incompetent vein (other than telangiectasia) Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS) Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions Ligation, division, and stripping, short saphenous vein 36475 36476 36478 36479 37500 37700 37718 Varicose Veins Treatment Payment Policy Page 4

  5. Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below 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 Ligation of perforator veins, subfascial, radical (Linton type), including skin graft, when performed, open,1 leg Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure) Ligation, division, and/or excision of varicose vein cluster(s), 1 leg Unlisted procedure, vascular surgery 37722 37735 37760 37761 37765 37780 37785 37799 V.Policy History Policy Number:MPP-0085-120717 Current Effective Date:07/03/2019 Original Document Effective Date: 07/17/2012 Previous Revision Dates: 06/12/2018 PAP Approved Date: 07/17/2012 Previous Policy Title: Treatment of Varicose Veins Varicose Veins Treatment Payment Policy Page 5