About this policy
The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (Please see "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. The patient's medical record must document the following: •history and physical findings supporting a diagnosis of symptomatic varicose veins; •failure of an adequate trial of conservative treatment as described in the "Indications" section of this LCD; •exclusion of other causes of edema, ulceration and pain in the limbs; •performance of appropriate tests to confirm the presence and location of incompetent perforating veins; •location and number of varicosities, level of incompetence of the vein and the veins involved; and •necessity of utilizing ultrasound guidance, if used. The medical record must also include pre-treatment photographs of the varicose veins for which claims for sclerotherapy are submitted to Medicare. These photographs must be made available to the carrier upon request for review. Not applicable Coverage for podiatrists is limited by scope of practice specific to the state in which the service is provided. Medicare recognizes that multiple injections are needed to perform sclerotherapy and that responses differ due to the anatomical site being treated. Medicare would not expect to see the following when performing sclerotherapy: •More than three sclerotherapy sessions for each leg. •Only one sclerotherapy service per treatment session should be reported for either leg, regardless of how many veins are treated per session. Patients are not expected to require ablation of the saphenous vein by radiofrequency or laser more than once for either leg. A duplex ultrasound examination will be allowed when performed within 1 week (preferably within 72 hours) of EFRA to check for any evidence of thrombus extension from the saphenofemoral junction into the deep system.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 36465 | HCPCS | Covered |
| 36466 | HCPCS | Covered |
| 36468 | HCPCS | Covered |
| 36470 | HCPCS | Covered |
| 36471 | HCPCS | Covered |
| 36473 | HCPCS | Covered |
| 36474 | HCPCS | Covered |
| 36475 | HCPCS | Covered |
| 36476 | HCPCS | Covered |
| 36478 | HCPCS | Covered |
| 36479 | HCPCS | Covered |
| 36482 | HCPCS | Covered |
| 36483 |