0744T — Insj bioprostc vlv fem vn
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Pre-procedure duplex ultrasonography performed in the standing or reverse Trendelenburg position documenting: vein diameter (GSV measured at the proximal thigh immediately below the saphenofemoral junction; SSV or Accessory measured immediately below the appropriate junction), and duration of reflux (>= 500 milliseconds for GSV/SSV/Accessory; >= 500 ms for perforator veins where applicable). For perforator vein ablation: recent duplex ultrasound study in standing or reverse Trendelenburg showing perforator vein size >= 3.5 mm; perforator reflux >= 500 ms; perforating vein lies beneath a healed or active venous stasis ulcer; and documentation that the insufficiency is not secondary to acute deep vein thrombosis. Clinical documentation of one of the required Functional or Physical Impairments when indicating ablation (one or more): skin ulceration; documented episode(s) of frank bleeding of the Varicose Vein due to erosion and/or trauma to the skin; documented superficial thrombophlebitis; documented venous stasis dermatitis causing Functional or Physical Impairment; or moderate to severe pain causing Functional or Physical Impairment (VCSS definitions referenced). For ligation at the saphenofemoral junction as a stand-alone procedure to prevent clot propagation: documentation of ascending superficial thrombophlebitis and failure or intolerance of anticoagulation therapy. Evidence of prior diagnostic evaluation as appropriate (e.g., preoperative venous duplex ultrasound to evaluate symptoms or suspected DVT). When using CPT-coded sclerotherapy for truncal veins (e.g., 36465/36466), documentation that injection of non-compounded foam sclerosant with ultrasound guided compression maneuvers was performed (inclusive of imaging guidance and monitoring). For sclerotherapy with CPT codes 36470/36471: documentation of session dates and that no more than three sessions per leg occurred within a rolling 12-month period when billing as medically necessary. General statement: 'Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage' and refer to the protocol titled Medical Records Documentation Used for Reviews. duplex ultrasound study performed in the standing or reverse Trendelenburg position that shows duration of reflux that is greater than or equal to 500 milliseconds (ms) for the GSV, SSV, or Accessory Veins evidence of perforator venous insufficiency measured by a recent duplex ultrasound study performed in the standing or reverse Trendelenburg position (for perforator procedures) perforating vein reflux of 500 ms or greater (documented on duplex) for perforator-related procedures [the incompetent perforator veins are] not secondary to acute deep vein thrombosis (must be documented) history of the medical condition(s) requiring treatment or surgical intervention, including DVT (deep vein thrombosis), aneurysm, tortuosity, and previous relevant vein procedure(s) prior therapies/treatments that have been tried, failed, or were contraindicated; include the dates, duration, reason for discontinuation, and complications (e.g., recurrent bleeding or significant hemorrhage, DVT or superficial vein thrombosis (SVT), etc.) validated functional disability scales where applicable, e.g., Venous Clinical Severity Score (VCSS) and Venous Disability Score (VDS) duplex ultrasound report/interpretation that documents reflux duration (>=500 ms) and anatomy (GSV, SSV, Accessory Veins, or perforators) as part of medical records used for review
Key Coverage Criteria
- The initial and subsequent treatment of the Great Saphenous Veins (GSV), Small Saphenous Veins (SSV), and Accessory Veins with radiofrequency ablation, endovenous laser ablation, Stripping with Ligation and excision, endovenous foam Sclerotherapy, and/or cyanoacrylate-based adhesive are considered reconstructive and medically necessary when all of the following criteria are met: Individual must have one of the following Functional or Physical Impairments: Skin ulceration; or Documented episode(s [...]
3 Active Policies
UHC-POL-surgical-ablative-procedures-venous-insufficiency-varicose-veins — Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins
UMR-POL-UMR-surgical-ablative-procedures-venous-insufficiency-varicose-veins — Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins
SUREST-POL-SUREST-surgical-ablative-procedures-venous-insufficiency-varicose-veins — Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins
Related Codes
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