CG-SURG-119 Treatment of Varicose Veins (Lower Extremities)

This policy addresses treatment of lower-extremity varicose veins, specifically endoluminal radiofrequency ablation (RFA), endoluminal laser ablation (EVLA), sclerotherapy/echosclerotherapy/ultrasound-guided foam sclerotherapy (UGFS, e.g., Varithena), the COMPASS protocol, and the VenoValve device. RFA and EVLA are covered as medically necessary only when all plan criteria (I–III) are met; they are not medically necessary when criteria are unmet, including for saphenous vein tributaries/extensions or as an alternative to perforator vein ligation. Sclerotherapy/UGFS, the COMPASS protocol, and the VenoValve are considered not medically necessary (e.g., for secondary varicose veins due to DVT or arteriovenous fistulae) and are not covered.

"Endoluminal radiofrequency ablationorendoluminal laser ablation:"

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