37204
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Baseline documentation of clinical status including CEAP classification (e.g., CEAP class C2 to C6 where applicable), Venous Clinical Severity Score (VCSS), and disease‑specific and generic quality‑of‑life measures (e.g., AVVQ, VEINES‑QOL/Sym, SF‑36, EQ‑5D) as used in trials.
- Record of exclusion criteria where applicable (e.g., documentation that patient does not have current DVT, serious arterial disease, active venous leg ulcer where excluded, or is not on contraindicated anticoagulation if study/exclusion applied).
- Documentation of the treated vein(s) (GSV or SSV), treated segment length and vein diameter (many studies reported target vein diameter and treatment length), and rationale for chosen technique (MOCA, CAC, EVLA, RFA, etc.).
- Post‑procedural duplex ultrasound to assess technical success/occlusion at planned intervals (examples from VeClose and other studies: day 3, 1 month, 3 months, 6 months, 12 months, 24 months; other studies used 1 week, 6 weeks, 3 months, 6 months).
Key Coverage Criteria
- Symptomatic varicose veins of the lower extremities (general indication for discussion of all listed therapies).
- Great saphenous vein (GSV) insufficiency / truncal GSV reflux — eligible for treatment with mechanochemical ablation (MOCA/Clarivein), cyanoacrylate adhesive closure (CAC/VenaSeal and similar), endovenous laser ablation (EVLA), radiofrequency ablation (RFA), ultrasound-guided foam sclerotherapy (UGFS), or conventional surgery (ligation and stripping) depending on clinical judgement.
- Small saphenous vein (SSV) insufficiency — CAC has evidence for use and yields similar symptomatic improvement as EVLA and RFA in some studies.
- Polidocanol (liquid or foam) sclerotherapy (including polidocanol endovenous microfoam/Varithena) for treatment of varicose veins of the lower extremities (as a minimally invasive option to reduce symptoms, complications and recurrence rates evaluated in trials and meta-analyses).
- Ambulatory selective variceal ablation under local anesthetic (ASVAL; isolated phlebectomy preserving incompetent GSV) for selected patients with symptomatic GSV incompetence (studied in early-stage/chronic venous disease classes such as CEAP C2–C4 and may be considered a less aggressive option in selected cases).
- External valvuloplasty (eVP) as a reconstructive surgical approach to restore terminal and pre-terminal valve function of the GSV in selected patients (reported to reduce GSV diameter and VCSS in observational series).
1 Active Policy
AETNA-CPB-0050 — Varicose Veins
Related Codes
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