Endovenous radiofrequency or laser ablation for Treatment of Varicose veins and Venous Insufficiency
Prior authorization is required for varicose vein and venous insufficiency treatments.

MEDICAL NECESSITY CRITERIA DOCUMENTATION

Documentation in the medical records indicates that all of the following criteria are met:

A. Documentation of the failure of three month Trial use of compression stockings and analgesics such as NSAIDs to treat the patient’s symptoms.

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B. Performance of lower extremity Duplex Venous Doppler ultrasound to demonstrate a patent deep venous system of bilateral extremities performed within the past six months.

C.  Documentation of venous insufficiency symptoms in the chart

List of Venous insufficiency symptoms and functional impairments:

1. Moderate to severe pain resulting in functional impairment that interferes with activities of daily living (e.g., inability to perform household chores, prolonged standing, or essential job functions).

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2. Venous stasis dermatitis (including refractory dependent edema, erythema, scaling, and brown discoloration of the ankle)

3. External hemorrhage of the varicose vein

4. Venous ulceration