Aetna · Clinical coverage policy

Aetna Varicose Veins coverage criteria

Aetna CPB 0050 covers treatment of symptomatic varicose veins (e.g., saphenous vein ablation/ligation/stripping, sclerotherapy, ambulatory/powered phlebectomy, perforator and accessory saphenous vein ablation, and valvular reconstruction for chronic venous insufficiency) only when duplex/Doppler ultrasound documents qualifying reflux (typically 500 ms or greater) and vein diameter, and the varicosities cause a serious clinical problem such as ulceration, significant hemorrhage, recurrent thrombophlebitis, or disabling pain/swelling. The key gate is failed conservative management (a 3-month trial including 20 mmHg-or-greater compression stockings), which is waived for persistent/recurrent disease after prior procedures in the same leg. Treatment of small veins (under 2.5 mm) and spider/reticular veins is considered cosmetic, and numerous newer or adjunct technologies (e.g., MOCA/ClariVein, cyanoacrylate adhesive/VenaSeal, ASVAL, external valvuloplasty, VeinGogh, growth-factor and gene testing) are experimental/investigational.

Policy CPB 0050 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0050

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0050 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Varicose Veins (CPT 36465), and what gets it denied?

Path
Aetna CPB 0050 covers treatment of symptomatic varicose veins (e.g., saphenous vein ablation/ligation/stripping, sclerotherapy, ambulatory/powered phlebectomy, perforator and accessory saphenous vein ablation, and valvular reconstruction for chronic venous insufficiency) only when duplex/Doppler ultrasound documents qualifying reflux (typically 500 ms or greater) and vein diameter, and the varicosities cause a serious clinical problem such as ulceration, significant hemorrhage, recurrent thrombophlebitis, or disabling pain/swelling. The key gate is failed conservative management (a 3-month trial including 20 mmHg-or-greater compression stockings), which is waived for persistent/recurrent disease after prior procedures in the same leg. Treatment of small veins (under 2.5 mm) and spider/reticular veins is considered cosmetic, and numerous newer or adjunct technologies (e.g., MOCA/ClariVein, cyanoacrylate adhesive/VenaSeal, ASVAL, external valvuloplasty, VeinGogh, growth-factor and gene testing) are experimental/investigational. Coverage criteria include: Great/small saphenous vein procedures (ligation, division, stripping, radiofrequency, or laser ablation) are medically necessary when ALL of the following are met: (1) Incompetence at the saphenofemoral junction or saphenopopliteal junction is documented by recent (performed within the past 6 months) Doppler or duplex ultrasound scanning; AND (2) ALL of: ultrasound-documented junctional reflux duration of 500 ms or greater in the saphenofemoral or saphenopopliteal vein to be treated; AND 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 saphenous varicosities result in ANY ONE of the following: [intractable ulceration secondary to venous stasis] OR [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 [EITHER recurrent superficial thrombophlebitis OR severe and persistent pain and swelling interfering with activities of daily living, AND symptoms persist despite a 3-month trial of conservative management (including medical grade (20 mmHg or greater) gradient support compression stockings)]; Conservative management trial WAIVED/EXCEPTION: A trial of conservative management is not required for persons with persistent or recurrent varicosities who have undergone prior endovenous catheter ablation procedures or stripping/division/ligation in the same leg because conservative management is unlikely to be successful; Perforating vein surgery or endovenous ablation is medically necessary when ALL of the following are met: (1) perforating vein diameter measured by recent ultrasound of 3.5 mm or greater; AND (2) outward flow duration of 500 msec or more; AND (3) perforating vein is located underneath an active or healed venous stasis ulcer (also known as CEAP C5 or C6); Endovenous ablation of accessory saphenous veins is medically necessary adjunctive treatment when ALL of: (1) the accessory vein is being treated or has previously been treated by one of the great/small saphenous vein procedures for incompetence (i.e., reflux) at the saphenofemoral junction or saphenopopliteal junction; AND (2) anatomically related persistent junctional reflux is demonstrated after the great or small saphenous veins have been removed or ablated; Initial endovenous ablation therapy of the first vein and of the second and subsequent veins in each affected extremity is medically necessary when criteria are met; thus one primary code and one secondary code for each affected leg are medically necessary for initial endovenous ablation treatment; Additional (repeat) endovenous ablation therapy is medically necessary for persons with persistent or recurrent junctional reflux of the greater saphenous vein or lesser saphenous vein following initial endovenous ablation therapy, ONLY IF there is documentation that the member continues to have symptoms AND ultrasound showing persistent junctional reflux; Doppler or duplex ultrasound studies are medically necessary prior to varicose vein treatment to assess the anatomy and determine whether there is significant reflux at the saphenofemoral or saphenopopliteal junction requiring surgical repair, and after completion of treatment to determine the success of the procedure and detect thrombosis; ultrasound guidance is inclusive of the VNUS or ELAS procedures; Liquid or foam sclerotherapy (endovenous chemical ablation) is medically necessary for symptomatic saphenous veins, varicose tributaries, accessory, and perforator veins when ALL of: (1) vein size is 2.5 mm or greater in diameter, measured by recent ultrasound; AND (2) varicosities result in ANY ONE of: [intractable ulceration secondary to venous stasis] OR [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 [EITHER recurrent superficial thrombophlebitis OR severe and persistent pain and swelling interfering with activities of daily living, AND symptoms persist despite a 3-month trial of conservative management (including medical grade (20 mmHg or greater) gradient support compression stockings)]; AND (3) if the member has incompetence (i.e., reflux) at the saphenofemoral junction, the junctional reflux is being treated by one or more of the endovenous ablation or ligation and division procedures to reduce the risk of varicose vein recurrence; Sclerotherapy treatment sessions: usually 1 to 3 injections are necessary to obliterate any vessel, and 10 to 40 vessels, or a set of up to 20 injections in each leg, may be treated during one treatment session; initially up to two sets of injections of sclerosing solution in multiple veins in each affected leg (i.e., a total of four sets if both legs are affected) are medically necessary when criteria are met; Additional sets of injections of sclerosing solution are medically necessary for persons with persistent or recurrent symptoms; Ultrasound-monitored or duplex-guided techniques for sclerotherapy are medically necessary ONLY when initially performed to determine the extent and configuration of varicose veins (they have not been shown to definitively increase effectiveness or safety; guided/monitoring techniques are of no proven value when performed solely to guide the needle or introduce the sclerosant); Ambulatory phlebectomy or transilluminated powered phlebectomy (TriVex) is medically necessary adjunctive treatment of symptomatic saphenous veins, varicose tributaries, accessory, and perforator veins when ALL of: (1) vein size is 2.5 mm or greater in diameter; AND (2) varicosities result in ANY ONE of: [intractable ulceration secondary to venous stasis] OR [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 [EITHER recurrent superficial thrombophlebitis OR severe and persistent pain and swelling interfering with activities of daily living, AND symptoms persist despite a 3-month trial of conservative management (including medical grade (20 mmHg or greater) gradient support compression stockings)]; AND (3) if the member has incompetence (i.e., reflux) at the saphenofemoral junction or saphenopopliteal junction, the junctional reflux is being treated by one or more of the great/small saphenous vein procedures to reduce the risk of varicose vein recurrence; Initially, up to two multiple stab phlebectomy incisions in each affected extremity (i.e., a total of four if both legs are affected) are medically necessary when criteria are met; additional multiple stab phlebectomy incisions are medically necessary for persons with persistent or recurrent symptoms; Valvular reconstruction is medically necessary for chronic venous insufficiency. Applies to 18 codes: 36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37700, 37718, 37722, 37735, 37760, 37765, 37766, 37780, 37785.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Recent (performed within the past 6 months) Doppler or duplex ultrasound scanning documenting incompetence at the saphenofemoral junction or saphenopopliteal junction; Ultrasound documentation of junctional reflux duration (500 ms or greater); Ultrasound measurement of vein diameter (meeting the applicable size threshold for the procedure); Documentation that varicosities result in a qualifying clinical symptom (intractable ulceration secondary to venous stasis, hemorrhage episode(s), recurrent superficial thrombophlebitis, or severe and persistent pain and swelling interfering with activities of daily living); Documentation of a 3-month trial of conservative management including medical grade (20 mmHg or greater) gradient support compression stockings (for the pain/swelling and thrombophlebitis indications); For additional/repeat endovenous ablation: documentation that the member continues to have symptoms and ultrasound showing persistent junctional reflux; Post-treatment ultrasound after completion of treatment to determine success of the procedure and detect thrombosis.
Trap
Policy exclusions and limitations: Ambulatory phlebectomy or transilluminated powered phlebectomy for treatment of junctional reflux is experimental, investigational, or unproven; Ambulatory selective variceal ablation under local anesthetic (the ASVAL procedure) for the treatment of symptomatic great saphenous vein is experimental, investigational, or unproven; Endomechanical or mechanochemical ablation (MOCA) (e.g., ClariVein) is experimental, investigational, or unproven; Endovenous ablation (laser or radiofrequency) for the treatment of reflux of the common femoral vein is experimental, investigational, or unproven; External valvuloplasty for the treatment of symptomatic great saphenous vein is experimental, investigational, or unproven; Measurements of plasma growth factors (e.g., angiopoietin-1 (ANG1), angiopoietin-2 (ANG2), epidermal growth factor (EGF), platelet-derived growth factor (PDGF), and vascular endothelial growth factor (VEGF)) for predicting adequacy of treatment and possibility of recurrence are experimental, investigational, or unproven; Micronized purified flavonoid fraction is experimental, investigational, or unproven; Peri-procedural thromboprophylaxis (including pharmacotherapy) for the prevention of deep vein thrombosis in varicose vein interventions is experimental, investigational, or unproven; Polymorphism genotyping of matrix metalloproteinases genes (e.g., MMP1, MMP2, MMP3, and MMP7) as markers of predisposition to varicose veins is experimental, investigational, or unproven; Sclerotherapy for treatment of reflux of iliac veins, the saphenofemoral junction, or saphenopopliteal junction is experimental, investigational, or unproven; sclerotherapy alone has not been shown to be effective for persons with reflux at the saphenofemoral or saphenopopliteal junctions; Synthetic matrix metalloproteinases inhibitors are experimental, investigational, or unproven; Transdermal laser treatment of large varicose veins is experimental, investigational, or unproven (transdermal Nd:YAG laser has been shown to be effective for telangiectasias and reticular veins, but treatment of these small veins is considered cosmetic); Use of medical adhesive (also referred to as cyanoacrylate superglue, n-butyl-cyanoacrylate) (e.g., VariClose Vein Sealing System, VenaSeal Closure System) is experimental, investigational, or unproven; VeinGogh Ohmic Thermolysis System is experimental, investigational, or unproven; VeinOPlus vascular device for the treatment of muscle atrophy due to varicose veins is experimental, investigational, or unproven; Endovenous ablation procedures are experimental, investigational, or unproven for treatment of varicose tributaries and accessory veins other than the accessory saphenous vein; Ambulatory phlebectomy and the TriVex system for veins less than 2.5 mm in diameter and all other indications are considered cosmetic / not covered; Asclera polidocanol injection is considered cosmetic (FDA approved for telangiectasias and reticular veins less than 3 mm, but treatment of these small veins is considered cosmetic); Photothermal sclerosis (also referred to as an intense pulsed light source, e.g., the PhotoDerm VascuLight, VeinLase), used to treat small veins such as small varicose veins and spider veins, is considered cosmetic / not covered; Sclerotherapy for treatment of veins less than 2.5 mm in diameter and for all other indications is considered cosmetic / not covered; Endovenous ablation procedures for all other indications than those listed in the medically necessary policy section are not covered; Asymptomatic varicose veins of lower extremities are not covered; Treatment of muscle wasting and atrophy not elsewhere classified (due to varicose veins) is not covered; Varicose veins of lower extremity in pregnancy are not covered; Superficial thrombophlebitis in pregnancy is not covered; Venous complication in pregnancy, unspecified, is not covered; Superficial thrombophlebitis in the puerperium is not covered; Varicose veins of lower extremity in the puerperium are not covered; Venous complication in the puerperium, unspecified, is not covered; Venous insufficiency (chronic) (peripheral) is not covered for saphenopopliteal reflux, not covered for common femoral reflux, and not covered for reflux of iliac veins. Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0050 — Varicose Veins

Coverage criteria

  • Great/small saphenous vein procedures (ligation, division, stripping, radiofrequency, or laser ablation) are medically necessary when ALL of the following are met: (1) Incompetence at the saphenofemoral junction or saphenopopliteal junction is documented by recent (performed within the past 6 months) Doppler or duplex ultrasound scanning; AND (2) ALL of: ultrasound-documented junctional reflux duration of 500 ms or greater in the saphenofemoral or saphenopopliteal vein to be treated; AND 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 saphenous varicosities result in ANY ONE of the following: [intractable ulceration secondary to venous stasis] OR [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 [EITHER recurrent superficial thrombophlebitis OR severe and persistent pain and swelling interfering with activities of daily living, AND symptoms persist despite a 3-month trial of conservative management (including medical grade (20 mmHg or greater) gradient support compression stockings)]
  • Conservative management trial WAIVED/EXCEPTION: A trial of conservative management is not required for persons with persistent or recurrent varicosities who have undergone prior endovenous catheter ablation procedures or stripping/division/ligation in the same leg because conservative management is unlikely to be successful
  • Perforating vein surgery or endovenous ablation is medically necessary when ALL of the following are met: (1) perforating vein diameter measured by recent ultrasound of 3.5 mm or greater; AND (2) outward flow duration of 500 msec or more; AND (3) perforating vein is located underneath an active or healed venous stasis ulcer (also known as CEAP C5 or C6)
  • Endovenous ablation of accessory saphenous veins is medically necessary adjunctive treatment when ALL of: (1) the accessory vein is being treated or has previously been treated by one of the great/small saphenous vein procedures for incompetence (i.e., reflux) at the saphenofemoral junction or saphenopopliteal junction; AND (2) anatomically related persistent junctional reflux is demonstrated after the great or small saphenous veins have been removed or ablated
  • Initial endovenous ablation therapy of the first vein and of the second and subsequent veins in each affected extremity is medically necessary when criteria are met; thus one primary code and one secondary code for each affected leg are medically necessary for initial endovenous ablation treatment
  • Additional (repeat) endovenous ablation therapy is medically necessary for persons with persistent or recurrent junctional reflux of the greater saphenous vein or lesser saphenous vein following initial endovenous ablation therapy, ONLY IF there is documentation that the member continues to have symptoms AND ultrasound showing persistent junctional reflux
  • Doppler or duplex ultrasound studies are medically necessary prior to varicose vein treatment to assess the anatomy and determine whether there is significant reflux at the saphenofemoral or saphenopopliteal junction requiring surgical repair, and after completion of treatment to determine the success of the procedure and detect thrombosis; ultrasound guidance is inclusive of the VNUS or ELAS procedures
  • Liquid or foam sclerotherapy (endovenous chemical ablation) is medically necessary for symptomatic saphenous veins, varicose tributaries, accessory, and perforator veins when ALL of: (1) vein size is 2.5 mm or greater in diameter, measured by recent ultrasound; AND (2) varicosities result in ANY ONE of: [intractable ulceration secondary to venous stasis] OR [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 [EITHER recurrent superficial thrombophlebitis OR severe and persistent pain and swelling interfering with activities of daily living, AND symptoms persist despite a 3-month trial of conservative management (including medical grade (20 mmHg or greater) gradient support compression stockings)]; AND (3) if the member has incompetence (i.e., reflux) at the saphenofemoral junction, the junctional reflux is being treated by one or more of the endovenous ablation or ligation and division procedures to reduce the risk of varicose vein recurrence
  • Sclerotherapy treatment sessions: usually 1 to 3 injections are necessary to obliterate any vessel, and 10 to 40 vessels, or a set of up to 20 injections in each leg, may be treated during one treatment session; initially up to two sets of injections of sclerosing solution in multiple veins in each affected leg (i.e., a total of four sets if both legs are affected) are medically necessary when criteria are met
  • Additional sets of injections of sclerosing solution are medically necessary for persons with persistent or recurrent symptoms
  • Ultrasound-monitored or duplex-guided techniques for sclerotherapy are medically necessary ONLY when initially performed to determine the extent and configuration of varicose veins (they have not been shown to definitively increase effectiveness or safety; guided/monitoring techniques are of no proven value when performed solely to guide the needle or introduce the sclerosant)
  • Ambulatory phlebectomy or transilluminated powered phlebectomy (TriVex) is medically necessary adjunctive treatment of symptomatic saphenous veins, varicose tributaries, accessory, and perforator veins when ALL of: (1) vein size is 2.5 mm or greater in diameter; AND (2) varicosities result in ANY ONE of: [intractable ulceration secondary to venous stasis] OR [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 [EITHER recurrent superficial thrombophlebitis OR severe and persistent pain and swelling interfering with activities of daily living, AND symptoms persist despite a 3-month trial of conservative management (including medical grade (20 mmHg or greater) gradient support compression stockings)]; AND (3) if the member has incompetence (i.e., reflux) at the saphenofemoral junction or saphenopopliteal junction, the junctional reflux is being treated by one or more of the great/small saphenous vein procedures to reduce the risk of varicose vein recurrence
  • Initially, up to two multiple stab phlebectomy incisions in each affected extremity (i.e., a total of four if both legs are affected) are medically necessary when criteria are met; additional multiple stab phlebectomy incisions are medically necessary for persons with persistent or recurrent symptoms
  • Valvular reconstruction is medically necessary for chronic venous insufficiency

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • Recent (performed within the past 6 months) Doppler or duplex ultrasound scanning documenting incompetence at the saphenofemoral junction or saphenopopliteal junction
  • Ultrasound documentation of junctional reflux duration (500 ms or greater)
  • Ultrasound measurement of vein diameter (meeting the applicable size threshold for the procedure)
  • Documentation that varicosities result in a qualifying clinical symptom (intractable ulceration secondary to venous stasis, hemorrhage episode(s), recurrent superficial thrombophlebitis, or severe and persistent pain and swelling interfering with activities of daily living)
  • Documentation of a 3-month trial of conservative management including medical grade (20 mmHg or greater) gradient support compression stockings (for the pain/swelling and thrombophlebitis indications)
  • For additional/repeat endovenous ablation: documentation that the member continues to have symptoms and ultrasound showing persistent junctional reflux
  • Post-treatment ultrasound after completion of treatment to determine success of the procedure and detect thrombosis

Frequently asked questions

When does Aetna cover Varicose Veins (CPT 36465), and what gets it denied?
Aetna CPB 0050 covers treatment of symptomatic varicose veins (e.g., saphenous vein ablation/ligation/stripping, sclerotherapy, ambulatory/powered phlebectomy, perforator and accessory saphenous vein ablation, and valvular reconstruction for chronic venous insufficiency) only when duplex/Doppler ultrasound documents qualifying reflux (typically 500 ms or greater) and vein diameter, and the varicosities cause a serious clinical problem such as ulceration, significant hemorrhage, recurrent thrombophlebitis, or disabling pain/swelling. The key gate is failed conservative management (a 3-month trial including 20 mmHg-or-greater compression stockings), which is waived for persistent/recurrent disease after prior procedures in the same leg. Treatment of small veins (under 2.5 mm) and spider/reticular veins is considered cosmetic, and numerous newer or adjunct technologies (e.g., MOCA/ClariVein, cyanoacrylate adhesive/VenaSeal, ASVAL, external valvuloplasty, VeinGogh, growth-factor and gene testing) are experimental/investigational. Coverage criteria include: Great/small saphenous vein procedures (ligation, division, stripping, radiofrequency, or laser ablation) are medically necessary when ALL of the following are met: (1) Incompetence at the saphenofemoral junction or saphenopopliteal junction is documented by recent (performed within the past 6 months) Doppler or duplex ultrasound scanning; AND (2) ALL of: ultrasound-documented junctional reflux duration of 500 ms or greater in the saphenofemoral or saphenopopliteal vein to be treated; AND 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 saphenous varicosities result in ANY ONE of the following: [intractable ulceration secondary to venous stasis] OR [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 [EITHER recurrent superficial thrombophlebitis OR severe and persistent pain and swelling interfering with activities of daily living, AND symptoms persist despite a 3-month trial of conservative management (including medical grade (20 mmHg or greater) gradient support compression stockings)]; Conservative management trial WAIVED/EXCEPTION: A trial of conservative management is not required for persons with persistent or recurrent varicosities who have undergone prior endovenous catheter ablation procedures or stripping/division/ligation in the same leg because conservative management is unlikely to be successful; Perforating vein surgery or endovenous ablation is medically necessary when ALL of the following are met: (1) perforating vein diameter measured by recent ultrasound of 3.5 mm or greater; AND (2) outward flow duration of 500 msec or more; AND (3) perforating vein is located underneath an active or healed venous stasis ulcer (also known as CEAP C5 or C6); Endovenous ablation of accessory saphenous veins is medically necessary adjunctive treatment when ALL of: (1) the accessory vein is being treated or has previously been treated by one of the great/small saphenous vein procedures for incompetence (i.e., reflux) at the saphenofemoral junction or saphenopopliteal junction; AND (2) anatomically related persistent junctional reflux is demonstrated after the great or small saphenous veins have been removed or ablated; Initial endovenous ablation therapy of the first vein and of the second and subsequent veins in each affected extremity is medically necessary when criteria are met; thus one primary code and one secondary code for each affected leg are medically necessary for initial endovenous ablation treatment; Additional (repeat) endovenous ablation therapy is medically necessary for persons with persistent or recurrent junctional reflux of the greater saphenous vein or lesser saphenous vein following initial endovenous ablation therapy, ONLY IF there is documentation that the member continues to have symptoms AND ultrasound showing persistent junctional reflux; Doppler or duplex ultrasound studies are medically necessary prior to varicose vein treatment to assess the anatomy and determine whether there is significant reflux at the saphenofemoral or saphenopopliteal junction requiring surgical repair, and after completion of treatment to determine the success of the procedure and detect thrombosis; ultrasound guidance is inclusive of the VNUS or ELAS procedures; Liquid or foam sclerotherapy (endovenous chemical ablation) is medically necessary for symptomatic saphenous veins, varicose tributaries, accessory, and perforator veins when ALL of: (1) vein size is 2.5 mm or greater in diameter, measured by recent ultrasound; AND (2) varicosities result in ANY ONE of: [intractable ulceration secondary to venous stasis] OR [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 [EITHER recurrent superficial thrombophlebitis OR severe and persistent pain and swelling interfering with activities of daily living, AND symptoms persist despite a 3-month trial of conservative management (including medical grade (20 mmHg or greater) gradient support compression stockings)]; AND (3) if the member has incompetence (i.e., reflux) at the saphenofemoral junction, the junctional reflux is being treated by one or more of the endovenous ablation or ligation and division procedures to reduce the risk of varicose vein recurrence; Sclerotherapy treatment sessions: usually 1 to 3 injections are necessary to obliterate any vessel, and 10 to 40 vessels, or a set of up to 20 injections in each leg, may be treated during one treatment session; initially up to two sets of injections of sclerosing solution in multiple veins in each affected leg (i.e., a total of four sets if both legs are affected) are medically necessary when criteria are met; Additional sets of injections of sclerosing solution are medically necessary for persons with persistent or recurrent symptoms; Ultrasound-monitored or duplex-guided techniques for sclerotherapy are medically necessary ONLY when initially performed to determine the extent and configuration of varicose veins (they have not been shown to definitively increase effectiveness or safety; guided/monitoring techniques are of no proven value when performed solely to guide the needle or introduce the sclerosant); Ambulatory phlebectomy or transilluminated powered phlebectomy (TriVex) is medically necessary adjunctive treatment of symptomatic saphenous veins, varicose tributaries, accessory, and perforator veins when ALL of: (1) vein size is 2.5 mm or greater in diameter; AND (2) varicosities result in ANY ONE of: [intractable ulceration secondary to venous stasis] OR [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 [EITHER recurrent superficial thrombophlebitis OR severe and persistent pain and swelling interfering with activities of daily living, AND symptoms persist despite a 3-month trial of conservative management (including medical grade (20 mmHg or greater) gradient support compression stockings)]; AND (3) if the member has incompetence (i.e., reflux) at the saphenofemoral junction or saphenopopliteal junction, the junctional reflux is being treated by one or more of the great/small saphenous vein procedures to reduce the risk of varicose vein recurrence; Initially, up to two multiple stab phlebectomy incisions in each affected extremity (i.e., a total of four if both legs are affected) are medically necessary when criteria are met; additional multiple stab phlebectomy incisions are medically necessary for persons with persistent or recurrent symptoms; Valvular reconstruction is medically necessary for chronic venous insufficiency. Applies to 18 codes: 36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37700, 37718, 37722, 37735, 37760, 37765, 37766, 37780, 37785. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Recent (performed within the past 6 months) Doppler or duplex ultrasound scanning documenting incompetence at the saphenofemoral junction or saphenopopliteal junction; Ultrasound documentation of junctional reflux duration (500 ms or greater); Ultrasound measurement of vein diameter (meeting the applicable size threshold for the procedure); Documentation that varicosities result in a qualifying clinical symptom (intractable ulceration secondary to venous stasis, hemorrhage episode(s), recurrent superficial thrombophlebitis, or severe and persistent pain and swelling interfering with activities of daily living); Documentation of a 3-month trial of conservative management including medical grade (20 mmHg or greater) gradient support compression stockings (for the pain/swelling and thrombophlebitis indications); For additional/repeat endovenous ablation: documentation that the member continues to have symptoms and ultrasound showing persistent junctional reflux; Post-treatment ultrasound after completion of treatment to determine success of the procedure and detect thrombosis. Policy exclusions and limitations: Ambulatory phlebectomy or transilluminated powered phlebectomy for treatment of junctional reflux is experimental, investigational, or unproven; Ambulatory selective variceal ablation under local anesthetic (the ASVAL procedure) for the treatment of symptomatic great saphenous vein is experimental, investigational, or unproven; Endomechanical or mechanochemical ablation (MOCA) (e.g., ClariVein) is experimental, investigational, or unproven; Endovenous ablation (laser or radiofrequency) for the treatment of reflux of the common femoral vein is experimental, investigational, or unproven; External valvuloplasty for the treatment of symptomatic great saphenous vein is experimental, investigational, or unproven; Measurements of plasma growth factors (e.g., angiopoietin-1 (ANG1), angiopoietin-2 (ANG2), epidermal growth factor (EGF), platelet-derived growth factor (PDGF), and vascular endothelial growth factor (VEGF)) for predicting adequacy of treatment and possibility of recurrence are experimental, investigational, or unproven; Micronized purified flavonoid fraction is experimental, investigational, or unproven; Peri-procedural thromboprophylaxis (including pharmacotherapy) for the prevention of deep vein thrombosis in varicose vein interventions is experimental, investigational, or unproven; Polymorphism genotyping of matrix metalloproteinases genes (e.g., MMP1, MMP2, MMP3, and MMP7) as markers of predisposition to varicose veins is experimental, investigational, or unproven; Sclerotherapy for treatment of reflux of iliac veins, the saphenofemoral junction, or saphenopopliteal junction is experimental, investigational, or unproven; sclerotherapy alone has not been shown to be effective for persons with reflux at the saphenofemoral or saphenopopliteal junctions; Synthetic matrix metalloproteinases inhibitors are experimental, investigational, or unproven; Transdermal laser treatment of large varicose veins is experimental, investigational, or unproven (transdermal Nd:YAG laser has been shown to be effective for telangiectasias and reticular veins, but treatment of these small veins is considered cosmetic); Use of medical adhesive (also referred to as cyanoacrylate superglue, n-butyl-cyanoacrylate) (e.g., VariClose Vein Sealing System, VenaSeal Closure System) is experimental, investigational, or unproven; VeinGogh Ohmic Thermolysis System is experimental, investigational, or unproven; VeinOPlus vascular device for the treatment of muscle atrophy due to varicose veins is experimental, investigational, or unproven; Endovenous ablation procedures are experimental, investigational, or unproven for treatment of varicose tributaries and accessory veins other than the accessory saphenous vein; Ambulatory phlebectomy and the TriVex system for veins less than 2.5 mm in diameter and all other indications are considered cosmetic / not covered; Asclera polidocanol injection is considered cosmetic (FDA approved for telangiectasias and reticular veins less than 3 mm, but treatment of these small veins is considered cosmetic); Photothermal sclerosis (also referred to as an intense pulsed light source, e.g., the PhotoDerm VascuLight, VeinLase), used to treat small veins such as small varicose veins and spider veins, is considered cosmetic / not covered; Sclerotherapy for treatment of veins less than 2.5 mm in diameter and for all other indications is considered cosmetic / not covered; Endovenous ablation procedures for all other indications than those listed in the medically necessary policy section are not covered; Asymptomatic varicose veins of lower extremities are not covered; Treatment of muscle wasting and atrophy not elsewhere classified (due to varicose veins) is not covered; Varicose veins of lower extremity in pregnancy are not covered; Superficial thrombophlebitis in pregnancy is not covered; Venous complication in pregnancy, unspecified, is not covered; Superficial thrombophlebitis in the puerperium is not covered; Varicose veins of lower extremity in the puerperium are not covered; Venous complication in the puerperium, unspecified, is not covered; Venous insufficiency (chronic) (peripheral) is not covered for saphenopopliteal reflux, not covered for common femoral reflux, and not covered for reflux of iliac veins. Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Varicose Veins?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Recent (performed within the past 6 months) Doppler or duplex ultrasound scanning documenting incompetence at the saphenofemoral junction or saphenopopliteal junction; Ultrasound documentation of junctional reflux duration (500 ms or greater); Ultrasound measurement of vein diameter (meeting the applicable size threshold for the procedure); Documentation that varicosities result in a qualifying clinical symptom (intractable ulceration secondary to venous stasis, hemorrhage episode(s), recurrent superficial thrombophlebitis, or severe and persistent pain and swelling interfering with activities of daily living); Documentation of a 3-month trial of conservative management including medical grade (20 mmHg or greater) gradient support compression stockings (for the pain/swelling and thrombophlebitis indications); For additional/repeat endovenous ablation: documentation that the member continues to have symptoms and ultrasound showing persistent junctional reflux; Post-treatment ultrasound after completion of treatment to determine success of the procedure and detect thrombosis.
What does Aetna exclude for Varicose Veins?
Policy exclusions and limitations: Ambulatory phlebectomy or transilluminated powered phlebectomy for treatment of junctional reflux is experimental, investigational, or unproven; Ambulatory selective variceal ablation under local anesthetic (the ASVAL procedure) for the treatment of symptomatic great saphenous vein is experimental, investigational, or unproven; Endomechanical or mechanochemical ablation (MOCA) (e.g., ClariVein) is experimental, investigational, or unproven; Endovenous ablation (laser or radiofrequency) for the treatment of reflux of the common femoral vein is experimental, investigational, or unproven; External valvuloplasty for the treatment of symptomatic great saphenous vein is experimental, investigational, or unproven; Measurements of plasma growth factors (e.g., angiopoietin-1 (ANG1), angiopoietin-2 (ANG2), epidermal growth factor (EGF), platelet-derived growth factor (PDGF), and vascular endothelial growth factor (VEGF)) for predicting adequacy of treatment and possibility of recurrence are experimental, investigational, or unproven; Micronized purified flavonoid fraction is experimental, investigational, or unproven; Peri-procedural thromboprophylaxis (including pharmacotherapy) for the prevention of deep vein thrombosis in varicose vein interventions is experimental, investigational, or unproven; Polymorphism genotyping of matrix metalloproteinases genes (e.g., MMP1, MMP2, MMP3, and MMP7) as markers of predisposition to varicose veins is experimental, investigational, or unproven; Sclerotherapy for treatment of reflux of iliac veins, the saphenofemoral junction, or saphenopopliteal junction is experimental, investigational, or unproven; sclerotherapy alone has not been shown to be effective for persons with reflux at the saphenofemoral or saphenopopliteal junctions; Synthetic matrix metalloproteinases inhibitors are experimental, investigational, or unproven; Transdermal laser treatment of large varicose veins is experimental, investigational, or unproven (transdermal Nd:YAG laser has been shown to be effective for telangiectasias and reticular veins, but treatment of these small veins is considered cosmetic); Use of medical adhesive (also referred to as cyanoacrylate superglue, n-butyl-cyanoacrylate) (e.g., VariClose Vein Sealing System, VenaSeal Closure System) is experimental, investigational, or unproven; VeinGogh Ohmic Thermolysis System is experimental, investigational, or unproven; VeinOPlus vascular device for the treatment of muscle atrophy due to varicose veins is experimental, investigational, or unproven; Endovenous ablation procedures are experimental, investigational, or unproven for treatment of varicose tributaries and accessory veins other than the accessory saphenous vein; Ambulatory phlebectomy and the TriVex system for veins less than 2.5 mm in diameter and all other indications are considered cosmetic / not covered; Asclera polidocanol injection is considered cosmetic (FDA approved for telangiectasias and reticular veins less than 3 mm, but treatment of these small veins is considered cosmetic); Photothermal sclerosis (also referred to as an intense pulsed light source, e.g., the PhotoDerm VascuLight, VeinLase), used to treat small veins such as small varicose veins and spider veins, is considered cosmetic / not covered; Sclerotherapy for treatment of veins less than 2.5 mm in diameter and for all other indications is considered cosmetic / not covered; Endovenous ablation procedures for all other indications than those listed in the medically necessary policy section are not covered; Asymptomatic varicose veins of lower extremities are not covered; Treatment of muscle wasting and atrophy not elsewhere classified (due to varicose veins) is not covered; Varicose veins of lower extremity in pregnancy are not covered; Superficial thrombophlebitis in pregnancy is not covered; Venous complication in pregnancy, unspecified, is not covered; Superficial thrombophlebitis in the puerperium is not covered; Varicose veins of lower extremity in the puerperium are not covered; Venous complication in the puerperium, unspecified, is not covered; Venous insufficiency (chronic) (peripheral) is not covered for saphenopopliteal reflux, not covered for common femoral reflux, and not covered for reflux of iliac veins. Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0050 — Varicose Veins

Related

Need this Aetna approval drafted?

Ask D3 builds the documentation checklist and a ready-to-send request from this policy's criteria — cited, free, no signup.

Ask D3 Free

Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0050 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.