Varicose Veins of the Lower Extremity, Treatment of

Endovenous ablation (RFA, EVLA, PEM, CAE, MOCA) is covered for symptomatic saphenous vein reflux only after a documented six-week trial of conservative therapy and documented saphenous reflux, using FDA-approved devices per IFU; tributary veins >4 mm may be treated when saphenous reflux is absent or eliminated. Coverage is restricted by vein size (≤12 mm for CAE/PEM/MOCA), absence of thrombosis or tortuosity (PEM exception), and several explicit exclusions including pregnancy-related new/worsening varicosities, coil embolization, non‑IFU equipment/sclerosants, and patients with severe distal arterial disease, obliterated deep venous system, sclerosant allergy, or hypercoagulable states.

"Endovenous ablation (RFA, EVLA, PEM, CAE, MOCA) for elimination of saphenous (GSV, AAGSV, SSV) reflux is medically necessary when the patient remains symptomatic after a six-week trial of conservat..."