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Recurrent superficial thrombophlebitis or.Saphenous varicosities result in either of the following, and symptoms persist despite a 3-month trial of conservative management Footnote1* (including prescription gradient support compression stockings).More than 1 episode of minor hemorrhage from a ruptured superficial varicosity or a single significant hemorrhage from a ruptured superficial varicosity, especially if transfusion of blood is required or.Intractable ulceration secondary to venous stasis or.Saphenous varicosities result in any of the following:.Vein size is 4.5 mm or greater in diameter measured by ultrasound below the saphenofemoral or saphenopopliteal junction (not valve diameter at junction) and.Ultrasound documented junctional reflux duration of 500 milliseconds (ms) or greater in the saphenofemoral or saphenopopliteal vein to be treated and.Incompetence at the saphenofemoral junction or saphenopopliteal junction is documented by recent (performed within the past 6 months) Doppler or duplex ultrasound scanning, and all of the following criteria are met: Endovenous laser ablation of the saphenous vein (ELAS) (also known as endovenous laser treatment (EVLT)).

Radiofrequency endovenous occlusion (VNUS procedure) and.

Great saphenous vein or small saphenous vein ligation / division / stripping.

This Clinical Policy Bulletin addresses treatment of varicose veins.Īetna considers the following procedures medically necessary for treatment of varicose veins: Number: 0050 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References

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