Yes when meets criteria below

Transcription

1 Vein Disease Treatment MP9241 Covered Service: Prior Authorization Required: Additional Information: Medicare Policy: BadgerCare Plus Policy: Yes when meets criteria below Yes None Dean Health Plan covers when Medicare also covers the benefit. Dean Health Plan covers when BadgerCare Plus also covers the benefit. Dean Health Plan Medical Policy: The decision regarding whether the requested procedure will be covered as medically necessary or excluded from coverage as cosmetic will require review of ALL of the following clinical information and documentation, and such other documentation as may be reasonably requested. 1.0 Current physician office notes with the history of the medical condition(s) requiring treatment or surgical intervention. This documentation must include ALL of the following: 1.1 Documentation of conservative management. Conservative management includes but is not limited to: walking, avoidance of prolonged standing, and frequent elevation of affected leg(s). AND 1.2 The patient has venous insufficiency and valvular reflux that is consistent with the nature of the complaint that results in a functional impairment that is recurrent or persistent in nature AND 1.3 The condition is causing the functional impairment (include the nature of the impairment) A written report, of a venous ultrasound study, utilizing B-mode imaging, spectral Doppler and color flow, performed with the patient standing or in reverse Trendelenburg position, demonstrating reflux, duration of reflux and documentation of vein size. Continuous wave hand-held Doppler is insufficient for these purposes. The function of the deep venous system should be addressed. Vein Disease Treatment 1 of 5

2 1.3.2 Documentation in physician office notes clearly describing any abnormalities that would account for the functional impairment described by the member. Functional impairment may include: Skin ulceration OR Documented episode(s) of frank bleeding of the varicose vein due to erosion of or trauma to the skin OR Documented superficial thrombophlebitis or documented venous stasis dermatitis OR Moderate or severe pain causing limitation of activities. 1.4 High quality color photographs detailing dermatological changes may be requested as part of the documentation. 1.5 Treatment plan that must include proposed procedures including CPT codes mapped to specific venous anatomic structures, and the expected outcome for the improvement of the functional deficit. 1.6 Each of the requested surgical excisions or catheter entry points should be reviewed independently for coverage. 2.0 Varicose vein treatments (radiofrequency ablation, endovenous laser ablation, stripping, ligation and excision) for the greater saphenous vein, small saphenous vein or principle branches require prior authorization and will be eligible for coverage when all of the following criteria are present. Only one procedure code submitted per named vein will be considered for each vein: 2.1 Condition is caused by venous insufficiency 2.2 Documentation in a signed report of duration of reflux, as measured by Spectral Wave Form study, in the standing or reverse Trendelenburg position that meets the following parameters: Greater than or equal to 500 milliseconds (ms) for the great saphenous, small saphenous or principle branches Perforating veins > 500 ms Some duplex ultrasound readings will describe this as moderate to severe reflux which will be acceptable. 3.0 Ablation of perforator veins require prior authorization and are considered reconstructive when the following criteria are present: 3.1 Evidence of perforator venous insufficiency measured by duplex ultrasonography report (see criteria above) AND 3.2 Perforator vein size is 3.5mm or greater AND Vein Disease Treatment 2 of 5

3 3.3 Documentation in office notes and Duplex Ultrasound Study that the perforating vein lays beneath a healed or active venous stasis ulcer. 4.0 Sclerotherapy requires prior authorization through the Quality and Care Management Division is considered medically necessary treatment under the following: 4.1 Symptomatic saphenous veins, varicose tributaries, accessory, and perforator veins 2.5 mm or greater in diameter measured by recent ultrasound AND 4.2 When criteria for varicose vein treatment in 1.0 is met AND 4.3 Are being treated or have previously been treated by one or more of procedures in 2.0 for incompetence. 4.4 Sclerotherapy is considered cosmetic for treatment of veins less than 2.5 mm in diameter. 5.0 Stab phlebectomy requires prior authorization and is considered medically necessary treatment under the following: 5.1 Symptomatic saphenous veins, varicose tributaries, accessory, and perforator veins 2.5 mm or greater in diameter measured by recent ultrasound AND 5.2 When criteria for varicose vein treatment in 1.0 is met AND 5.3 Are being treated or have previously been treated by one or more of procedures in 2.0 for incompetence. 5.4 Stab phlebectomy may be done in conjunction with a procedure in The following procedures/services are considered cosmetic and therefore are not a covered benefit 6.1 Treatment of spider veins or telangiestasia, and nonsymptomatic varicose veins 6.2 Ligation performed without stripping or ablation is associated with high long-term recurrence rates due to neovascularization 6.3 Ligation of the great saphenous or small saphenous vein at the saphenofemoral junction, as stand-alone procedures, are unproven for treating venous reflux 6.4 Sclerotherapy for vessels larger than five (5) mm in diameter 6.5 Reinjection following recanalization or failure of vein closure without recurrent signs or symptoms 6.6 Noncompressive sclerotherapy 6.7 Compressive sclerotherapy for large, extensive or truncal varicosities 6.8 Sclerotherapy of the saphenous vein at its junction with the deep venous system 6.9 Sclerotherapy, ligation and/or stripping of varicose veins, or endovenous ablation therapy are not covered for pregnant women, patients on anticoagulant therapy, or patients with the inability to tolerate compressive Vein Disease Treatment 3 of 5

4 bandages or stockings; severe distal arterial occlusive disease; obliteration of deep venous system; an allergy to the sclerosant; or a hypercoaguable state 6.10Any interventional treatment that uses equipment not approved for such purposes by the FDA Committee/Source Date(s) Originated: Utilization Management Committee June 14, 2000 Revised: Reviewed: Medicare Part B, 10/2003 / Referral Staff Utilization Management Committee/ Medical Affairs Medical Director Committee/Quality and Care Managed Care Division/ Medical Affairs Department HAYES 5/2001 Utilization Management Committee/CMO/UM Director HAYES Medicare Part B, 12/2004 / HAYES, Inc, 12/2004 January 14, 2004 June 9, 2004 July 14, 2004 August 11, 2004 November 11, 2004 August 9, 2006 October 11, 2006 November 11, 2009 April 14, 2010 June 9, 2010 April 28, 2011 May 16, 2012 April 17, 2013 January 21, 2015 March 18, 2015 July 15, 2015 December 16, 2015 April 11, 2001 October 10, 2001 March 13, 2002 March 12, 2003 March 10, 2004 January 12, 2005 February 9, 2005 Vein Disease Treatment 4 of 5

5 Reviewed: Committee/Source Medical Director Committee/Quality and Care Medical Policy Committee/Quality and Care Date(s) March 9, 2005 March 8, 2006 March 14, 2007 March 12, 2008 July 9, 2008 April 8, 2009 April 14, 2010 June 9, 2010 April 28, 2011 May 16, 2012 August 15, 2012 April 17, 2013 April 16, 2014 January 21, 2015 March 18, 2015 April 15, 2015 July 15, 2015 December 19, 2015 April 20, 2016 Effective: 05/01/2016 Vein Disease Treatment 5 of 5