Treatment of Varicose Veins Policy Number: PG0091 ADVANTAGE | ELITE

Treatment of Varicose Veins Policy Number: PG0091 ADVANTAGE | ELITE | HMO Last Review: 01/09/2018

INDIVIDUAL MARKETPLACE | PROMEDICA MEDICARE PLAN | PPO GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement.

SCOPE X Professional _ Facility

DESCRIPTION Varicose veins result from weakening or incompetence of a one-way valve, leading to reflux (i.e., reverse flow) of blood in the vessel. The varicosity may vary in size from 3–10 mm, on average. Symptoms that have been reported as associated with varicose veins of the lower extremities result from inadequate emptying of the vein (i.e., venous insufficiency) and include pain, cramping, aching, burning, throbbing, swelling and the feeling of heaviness or fatigue in the leg. Typically, symptoms are exacerbated by standing and warm weather. Saphenous varicose veins can ultimately result in intractable ulcerations and recurrent bleeding. Patients with larger varicosities (e.g., varicose veins greater than 3 mm in diameter) are more prone to thrombophlebitis and other complications than those with smaller varicosities. Chronic cellulitis may also be associated with varicosities.

Telangiectases, also called spider veins, are permanently dilated blood vessels that create fine red or blue lines on the skin. They are similar to varicose veins, but are limited to the dermis and are not usually more than 3mm in diameter. While these are potentially unattractive, they are a benign condition. They most commonly occur on the legs, but may also occur on the face and other locations. Spider veins do not usually cause symptoms, and their repair is considered cosmetic in nature; hence, treatment for them is not medically necessary.

Several treatment options are available for the treatment of symptomatic varicose veins, including ligation and stripping, subfascial endoscopic surgery and ablative procedures. Procedures such as sclerotherapy and phlebectomy are effective for treatment of secondary varicose tributaries when either performed at the same time or following an initial invasive procedure. The peer-reviewed scientific literature supports safety and efficacy of these procedures, with most patients obtaining improvement in clinical outcomes. While varicose vein surgery is a very common surgical procedure, there is no general consensus regarding the best surgical approach. Additionally, recurrences have been reported requiring second treatment sessions for some procedures.

Evidence in the medical literature evaluating procedures such as trans illuminated powered phlebectomy, endomechanical ablative approaches and cryoablative procedures is primarily in the form of case series, lack randomization and controls, and involve small sample populations evaluating short-term outcomes. Strong evidence based conclusions cannot be made regarding safety, efficacy, and improvement of net health outcomes. Further clinical studies are needed to support the safety and efficacy of these procedures.

PG0091 – 12/14/2020 POLICY Does Not Require Prior Authorization for All Product Lines Appropriate ICD-10 diagnosis code required for coverage Stab Phlebectomy (37765, 37766) Ligation and Excision (37700, 37718, 37722, 37735, 37780, 37785) Radiofrequency Ablation (RFA) (36475, 36476) Endovenous Laser Therapy (EVLT) (36478, 36479) Compounded foam sclerotherapy ablations (36470, 36471, S2202 Non-Medicare) Subfascial Endoscopic Perforator Surgery (SEPS) (37500, 37760, 37761) Sclerotherapy using Ultrasound Guidance and a Microfoam Sclerosant (e.g., Varithena™) (36465, 36466) Endovascular Ablation Cyanoacrylate Adhesive (e.g., VenaSeal Closure System) (36482, 36483)

Does Not Require Prior Authorization for Advantage Appropriate ICD-10 diagnosis code required for coverage Endomechanical Ablative Approach (MOCA, MCEA, MEECA) (36473, 36474, 37241, 37244, 75894) Coil Embolization (37241)

Non-Covered for HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan Endomechanical Ablative Approach (MOCA, MCEA, MEECA) (36473, 36474, 37241, 37244, 75894) Coil Embolization (37241)

Non-Covered for All Product Lines Sclerotherapy for Treatment of Telangiectasia (36468) Transilluminated Powered Phlebectomy (TIPP, TriVex™) (37799) Cryostripping (including cryoablation and cryofreezing) (37799)

COVERAGE CRITERIA HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, Advantage Coverage for treatment of varicose veins is dependent on benefit plan language and may be subject to the provisions of a cosmetic and/or reconstructive surgery benefit. Under many benefit plans, treatment of varicose veins is not covered when provided solely for the purpose of altering appearance or self-esteem or to treat psychological symptomatology or psychosocial complaints related to one’s appearance. In addition, some benefit plans specifically exclude coverage for the invasive treatment of varicose veins. Please refer to the applicable benefit plan document to determine benefit availability and the terms, conditions and limitations of coverage.

If coverage is available for the treatment of varicose veins, the following conditions of coverage apply.

Varicose vein treatment is a covered benefit when medically necessary as outlined below. Treatment of varicose veins (36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, & S2202) is covered for ICD-10 diagnosis codes as listed below. When a diagnosis as listed below is not billed in one of the first five diagnosis fields on the claim form, the procedure will be denied.

Treatment of varicose veins is considered reasonable and medically necessary when ALL of the following exists:  The patient is symptomatic and has one or more of the following: 1. Documented history of complications of venous stasis (dermatitis, ulceration, subcutaneous induration) 2. History of hemorrhage of large varicosities 3. Significant leg aching, heaviness, or cramps and/or swelling during activity or after prolonged standing, severe enough to impair mobility 4. Recurrent episodes of superficial phlebitis in the affected area 5. Refractory dependent edema due to the varicosities  A three-month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, compressive therapy, and avoidance of prolonged immobility where appropriate, has failed

PG0091 – 12/14/2020  Maximum vein diameter of 20 mm for RFA or 30 mm for EVLT  Absence of thrombosis or significant vein tortuosity, which would impair catheter advancement  Absence of significant peripheral arterial diseases

A. Varicose vein treatments that may be considered for coverage include the following modalities, as a single or combined treatment, when medical necessity criteria above and the specific criteria for the procedure(s) outlined below are met:  Stab Phlebectomy (37765, 37766)  Ligation and Excision (37700, 37718, 37722, 37735, 37780, 37785)  Radiofrequency Ablation (RFA) (36475, 36476) of greater and/or lesser saphenous vein, if ultrasound shows evidence of venous reflux. RFA for perforator veins is a covered benefit when ALL of the following are met: 1. Doppler and/or Duplex ultrasonography evaluation and report, performed no more than 12 months prior to the requested procedure, confirms reflux of the incompetent perforator vein and location on the medial aspect of the calf being treated 2. Failure or intolerance of medically supervised conservative management, including but not limited to compression stocking therapy, for at least three consecutive months 3. Documentation of at least ONE of the following conditions: o venous stasis dermatitis/ulceration o chronic venous insufficiency  Endovenous Laser Therapy (EVLT) (36478, 36479) of greater and/or lesser saphenous vein, if ultrasound shows evidence of venous reflux  Sclerotherapy (36465, 36466, 36470, 36471, S2202) (liquid, foam, ultrasound-guided, or endovenous chemical ablation, endovenous microfoam) using a sclerosant approved by the U.S. Food and Drug Administration for the intended use  Endovascular Ablation Cyanoacrylate Adhesive (e.g., VenaSeal Closure System) (36482, 36483) is covered only for the treatment of symptomatic varicosities of the lesser or greater saphenous veins and their tributaries which have failed 3 months of conservative therapy.  Subfascial Endoscopic Perforator Surgery (SEPS) (37500, 37760, 37761) is a covered benefit when ALL of the following are met: 1. Doppler and/or Duplex ultrasonography, performed no more than 12 months prior to the requested procedure, confirms reflux of the incompetent perforator vein and location on the medial aspect of the calf being treated. 2. Failure or intolerance of medically supervised conservative management, including but not limited to compression stocking therapy, for at least three consecutive months 3. Documentation of at least ONE of the following conditions: o venous stasis dermatitis/ulceration o chronic venous insufficiency

If varicose vein procedures (37760 or 37761) are denied, then codes 76937, 76942, 76998, & 93971 if billed on the same claim, will be denied as well as they are secondary procedures to the varicose vein procedure.

NON-COVERED Varicose Vein Treatments

A. The following procedures are non-covered as there is insufficient evidence to conclude benefits and efficacy:  Transilluminated Powered Phlebectomy (TIPP, TriVex™) (37799)  Cryostripping (including cryoablation and cryofreezing) (37799) of any vein  Non-compressive sclerotherapy  Transdermal laser therapy  SEPS for the treatment of venous insufficiency as a result of post-thrombotic syndrome  Sclerotherapy (i.e., liquid, foam, ultra-sound guided, endovenous chemical ablation, endovenous microfoam) when performed for ANY of the following indications: 1. Sole treatment of accessory, reticular or varicose tributaries without associated occlusion of the saphenofemoral or saphenopopliteal junction 2. Incompetence that is isolated to the perforator veins

PG0091 – 12/14/2020 3. Of the Greater Saphenous Vein (GSV), with or without associated ligation of the saphenofemoral junction 4. As a sole (i.e., standalone) treatment for reflux occurring at the saphenofemoral or saphenopopliteal junction

B. The following procedures are non-covered as each is considered cosmetic in nature and not medically necessary:  Sclerotherapy for Treatment of Telangiectasia (36468) or varicose veins that are less than 3 mm in diameter by any method  Sclerotherapy with glycerin/glycerol

Paramount cannot cover services which are not reasonable and necessary for the treatment of illness or injury or to improve the functioning of a malformed body member.

HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan The following procedures are non-covered as there is insufficient evidence to conclude benefits and efficacy:  Endomechanical Ablative Approach (36473, 36474, 37241, 37244, 75894) using rotating catheter (e.g., ClariVein™ Catheter) (e.g., mechanical occlusion chemically assisted ablation [MOCA], mechanic-chemical endovenous ablation [MCEA], mechanically enhanced endovenous chemical ablation [MEECA)  Coil Embolization (37241)

Advantage While there is insufficient evidence in the published medical literature to demonstrate the safety, efficacy and long- term outcomes of Endomechanical Ablative Approach (36473, 36474, 37241, 37244, 75894) & Coil Embolization (37241), The Ohio Department of Medicaid requires these procedures be covered for Advantage members when medical necessity criteria above are met including appropriate ICD-10 diagnosis code requirement.

CODING/BILLING INFORMATION The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered.

CPT CODES 36465 Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous vein) (New code effective 01/01/2018) 36466 Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg (New code effective 01/01/2018) 36468 Injection(s) of sclerosant for spider veins (telangiectasia); limb or trunk 36470 Injection of sclerosant; single incompetent vein (other than telangiectasia) 36471 Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg 36473 Endovenous ablation therapy of incompetent vein, extremity inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated 36474 Endovenous ablation therapy of incompetent vein, extremity inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) 36475 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated 36476 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and

PG0091 – 12/14/2020 monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) 36478 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser,; first vein treated 36479 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) 36482 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated (New code effective 01/01/2018) 36483 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) (New code effective 01/01/2018) 37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) 37244 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation 37500 Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS) 37700 Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions 37718 Ligation, division, and stripping, short saphenous vein 37722 Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below 37735 Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer and skin graft and/or interruption of communicating veins of lower leg, with excision of deep fascia 37760 Ligation of perforator veins, subfascial, radical (Linton type), including skin graft, when performed, open, 1 leg 37761 Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg 37765 Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions 37766 Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions 37780 Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure) 37785 Ligation, division, and/or excision of varicose vein cluster(s), 1 leg 37799 Unlisted procedure, vascular surgery 75894 Transcatheter therapy, embolization, any method, radiological supervision and interpretation 76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting 76942 Ultrasonic guidance for needle placement imaging supervision and interpretation 76998 Other diagnostic ultrasound procedures 93971 Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study HCPCS CODE S2202 Echosclerotherapy ICD-10-CM CODES REQUIRED FOR COVERAGE I78.0 Hereditary hemorrhagic telangiectasia I80.00 Phlebitis and thrombophlebitis of superficial vessels of unspecified lower extremity

PG0091 – 12/14/2020 I80.01 Phlebitis and thrombophlebitis of superficial vessels of right lower extremity I80.02 Phlebitis and thrombophlebitis of superficial vessels of left lower extremity I80.03 Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateral I80.10 Phlebitis and thrombophlebitis of unspecified femoral vein I80.11 Phlebitis and thrombophlebitis of right femoral vein I80.12 Phlebitis and thrombophlebitis of left femoral vein I80.13 Phlebitis and thrombophlebitis of femoral vein, bilateral I80.201 Phlebitis and thrombophlebitis of unspecified deep vessels of right lower extremity I80.202 Phlebitis and thrombophlebitis of unspecified deep vessels of left lower extremity I80.203 Phlebitis and thrombophlebitis of unspecified deep vessels of lower extremities, bilateral I80.209 Phlebitis and thrombophlebitis of unspecified deep vessels of unspecified lower extremity I80.211 Phlebitis and thrombophlebitis of right iliac vein I80.212 Phlebitis and thrombophlebitis of left iliac vein I80.213 Phlebitis and thrombophlebitis of iliac vein, bilateral I80.219 Phlebitis and thrombophlebitis of unspecified iliac vein I80.221 Phlebitis and thrombophlebitis of right popliteal vein I80.222 Phlebitis and thrombophlebitis of left popliteal vein I80.223 Phlebitis and thrombophlebitis of popliteal vein, bilateral I80.229 Phlebitis and thrombophlebitis of unspecified popliteal vein I80.231 Phlebitis and thrombophlebitis of right tibial vein I80.232 Phlebitis and thrombophlebitis of left tibial vein I80.233 Phlebitis and thrombophlebitis of tibial vein, bilateral I80.239 Phlebitis and thrombophlebitis of unspecified tibial vein I80.291 Phlebitis and thrombophlebitis of other deep vessels of right lower extremity I80.292 Phlebitis and thrombophlebitis of other deep vessels of left lower extremity I80.293 Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral I80.299 Phlebitis and thrombophlebitis of other deep vessels of unspecified lower extremity I80.3 Phlebitis and thrombophlebitis of lower extremities, unspecified I80.8 Phlebitis and thrombophlebitis of other sites I80.9 Phlebitis and thrombophlebitis of unspecified site I82.401 Acute embolism and thrombosis of unspecified deep veins of right lower extremity I82.402 Acute embolism and thrombosis of unspecified deep veins of left lower extremity I82.403 Acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral I82.409 Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity I82.411 Acute embolism and thrombosis of right femoral vein I82.412 Acute embolism and thrombosis of left femoral vein I82.413 Acute embolism and thrombosis of femoral vein, bilateral I82.419 Acute embolism and thrombosis of unspecified femoral vein I82.421 Acute embolism and thrombosis of right iliac vein I82.422 Acute embolism and thrombosis of left iliac vein I82.423 Acute embolism and thrombosis of iliac vein, bilateral I82.429 Acute embolism and thrombosis of unspecified iliac vein I82.431 Acute embolism and thrombosis of right popliteal vein I82.432 Acute embolism and thrombosis of left popliteal vein I82.433 Acute embolism and thrombosis of popliteal vein, bilateral I82.439 Acute embolism and thrombosis of unspecified popliteal vein I82.441 Acute embolism and thrombosis of right tibial vein I82.442 Acute embolism and thrombosis of left tibial vein I82.443 Acute embolism and thrombosis of tibial vein, bilateral I82.449 Acute embolism and thrombosis of unspecified tibial vein I82.491 Acute embolism and thrombosis of other specified deep vein of right lower extremity I82.492 Acute embolism and thrombosis of other specified deep vein of left lower extremity

PG0091 – 12/14/2020 I82.493 Acute embolism and thrombosis of other specified deep vein of lower extremity, bilateral I82.499 Acute embolism and thrombosis of other specified deep vein of unspecified lower extremity I82.501 Chronic embolism and thrombosis of unspecified deep veins of right lower extremity I82.502 Chronic embolism and thrombosis of unspecified deep veins of left lower extremity I82.503 Chronic embolism and thrombosis of unspecified deep veins of lower extremity, bilateral I82.509 Chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity I82.511 Chronic embolism and thrombosis of right femoral vein I82.512 Chronic embolism and thrombosis of left femoral vein I82.513 Chronic embolism and thrombosis of femoral vein, bilateral I82.519 Chronic embolism and thrombosis of unspecified femoral vein I82.521 Chronic embolism and thrombosis of right iliac vein I82.522 Chronic embolism and thrombosis of left iliac vein I82.523 Chronic embolism and thrombosis of iliac vein, bilateral I82.529 Chronic embolism and thrombosis of unspecified iliac vein I82.531 Chronic embolism and thrombosis of right popliteal vein I82.532 Chronic embolism and thrombosis of left popliteal vein I82.533 Chronic embolism and thrombosis of popliteal vein, bilateral I82.539 Chronic embolism and thrombosis of unspecified popliteal vein I82.541 Chronic embolism and thrombosis of right tibial vein I82.542 Chronic embolism and thrombosis of left tibial vein I82.543 Chronic embolism and thrombosis of tibial vein, bilateral I82.549 Chronic embolism and thrombosis of unspecified tibial vein I82.591 Chronic embolism and thrombosis of other specified deep vein of right lower extremity I82.592 Chronic embolism and thrombosis of other specified deep vein of left lower extremity I82.593 Chronic embolism and thrombosis of other specified deep vein of lower extremity, bilateral I82.599 Chronic embolism and thrombosis of other specified deep vein of unspecified lower extremity I82.5Y1 Chronic embolism and thrombosis of unspecified deep veins of right proximal lower extremity I82.5Y2 Chronic embolism and thrombosis of unspecified deep veins of left proximal lower extremity I82.5Y3 Chronic embolism and thrombosis of unspecified deep veins of proximal lower extremity, bilateral I82.5Y9 Chronic embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity I82.5Z1 Chronic embolism and thrombosis of unspecified deep veins of right distal lower extremity I82.5Z2 Chronic embolism and thrombosis of unspecified deep veins of left distal lower extremity I82.5Z3 Chronic embolism and thrombosis of unspecified deep veins of distal lower extremity, bilateral I82.5Z9 Chronic embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity I83.011 Varicose veins of right lower extremity with ulcer of thigh I83.012 Varicose veins of right lower extremity with ulcer of calf I83.013 Varicose veins of right lower extremity with ulcer of ankle I83.014 Varicose veins of right lower extremity with ulcer of heel and midfoot I83.015 Varicose veins of right lower extremity with ulcer other part of foot I83.021 Varicose veins of left lower extremity with ulcer of thigh I83.022 Varicose veins of left lower extremity with ulcer of calf I83.023 Varicose veins of left lower extremity with ulcer of ankle I83.024 Varicose veins of left lower extremity with ulcer of heel and midfoot I83.025 Varicose veins of left lower extremity with ulcer other part of foot I83.11 Varicose veins of right lower extremity with inflammation I83.12 Varicose veins of left lower extremity with inflammation I83.211 Varicose veins of right lower extremity with both ulcer of thigh and inflammation I83.212 Varicose veins of right lower extremity with both ulcer of calf and inflammation I83.213 Varicose veins of right lower extremity with both ulcer of ankle and inflammation I83.214 Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation I83.215 Varicose veins of right lower extremity with both ulcer other part of foot and inflammation

PG0091 – 12/14/2020 I83.218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation I83.221 Varicose veins of left lower extremity with both ulcer of thigh and inflammation I83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammation I83.223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation I83.224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation I83.225 Varicose veins of left lower extremity with both ulcer other part of foot and inflammation I83.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation I83.811 Varicose veins of right lower extremities with pain I83.812 Varicose veins of left lower extremities with pain I83.813 Varicose veins of bilateral lower extremities with pain I83.891 Varicose veins of right lower extremities with other complications I83.892 Varicose veins of left lower extremities with other complications I83.893 Varicose veins of bilateral lower extremities with other complications I87.011 Postthrombotic syndrome with ulcer of right lower extremity I87.012 Postthrombotic syndrome with ulcer of left lower extremity I87.013 Postthrombotic syndrome with ulcer of bilateral lower extremity I87.019 Postthrombotic syndrome with ulcer of unspecified lower extremity I87.021 Postthrombotic syndrome with inflammation of right lower extremity I87.022 Postthrombotic syndrome with inflammation of left lower extremity I87.023 Postthrombotic syndrome with inflammation of bilateral lower extremity I87.029 Postthrombotic syndrome with inflammation of unspecified lower extremity I87.031 Postthrombotic syndrome with ulcer and inflammation of right lower extremity I87.032 Postthrombotic syndrome with ulcer and inflammation of left lower extremity I87.033 Postthrombotic syndrome with ulcer and inflammation of bilateral lower extremity I87.039 Postthrombotic syndrome with ulcer and inflammation of unspecified lower extremity I87.091 Postthrombotic syndrome with other complications of right lower extremity I87.092 Postthrombotic syndrome with other complications of left lower extremity I87.093 Postthrombotic syndrome with other complications of bilateral lower extremity I87.099 Postthrombotic syndrome with other complications of unspecified lower extremity I87.2 Venous insufficiency (chronic) (peripheral) I87.311 Chronic venous hypertension (idiopathic) with ulcer of right lower extremity I87.312 Chronic venous hypertension (idiopathic) with ulcer of left lower extremity I87.313 Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity I87.321 Chronic venous hypertension (idiopathic) with inflammation of right lower extremity I87.322 Chronic venous hypertension (idiopathic) with inflammation of left lower extremity I87.323 Chronic venous hypertension (idiopathic) with inflammation of bilateral lower extremity I87.331 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity I87.332 Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity I87.333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity I87.391 Chronic venous hypertension (idiopathic) with other complications of right lower extremity I87.392 Chronic venous hypertension (idiopathic) with other complications of left lower extremity I87.393 Chronic venous hypertension (idiopathic) with other complications of bilateral lower extremity I87.8 Other specified disorders of veins

REVISION HISTORY EXPLANATION ORIGINAL EFFECTIVE DATE: 03/15/2007 04/15/08: No change 04/30/09: Updated references 07/24/12: No changes

PG0091 – 12/14/2020 09/08/15: Removed deleted code 36469. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 06/13/17: Changed title from Treatment of Spider Veins to Treatment of Varicose Veins. Added codes 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, & S2202 as covered without prior authorization for all product lines. Added unlisted code 37799. Added codes 36473, 36474, 37241, 37244, 75894 as covered without prior authorization for Advantage and non-covered for HMO, PPO, Individual Marketplace, & Elite. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 08/08/17: Treatment of varicose veins (36470, 36471, 36475, 36476, 36478, 36479, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, & S2202) is covered when billed with an ICD-10 diagnoses code that was added to policy. When these diagnoses are not billed, these procedures will be denied. If varicose vein procedures (37760 or 37761) are denied, then codes (76937, 76942, 76998, 93971), if billed on the same claim, will be denied as well since as they are secondary procedures to the varicose veins procedure. Clarified that code S2202 is Non-Medicare. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 01/09/18: Revised codes 36468-36471 effective 01/01/18. Added effective 01/01/18 new codes 36465, 36466, 36482, & 36483 as covered when billed with ICD-10 diagnosis codes listed in the policy. When these diagnoses are not billed, these procedures will be denied. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 12/14/2020: Medical policy placed on the new Paramount Medical policy format

REFERENCES/RESOURCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets Industry Standard Review Hayes, Inc.

PG0091 – 12/14/2020