SURGICAL AND ABLATIVE PROCEDURES FOR VENOUS INSUFFICIENCY AND VARICOSE VEINS

SURGICAL AND ABLATIVE PROCEDURES FOR VENOUS INSUFFICIENCY AND VARICOSE VEINS Protocol: SUR037 Effective Date: 5/1/2015 Table of Contents COMMERCIAL INDICATIONS FOR COVERAGE DEFINITIONS MEDICARE AND MEDICAID RATIONALE DESCRIPTION OF SERVICES CLINICAL EVIDENCE U.S. FOOD AND DRUG ADMINISTRATION (FDA) APPLICABLE CODES REFERENCES PROTOCOL HISTORY/REVISION INFORMATION INSTRUCTIONS FOR USE This protocol provides assistance in interpreting UnitedHealthcare benefit plans. When deciding coverage, the enrollee specific document must be referenced. The terms of an enrollee's document (e.g., Certificate of Coverage (COC) or Evidence of Coverage (EOC) may differ greatly. In the event of a conflict, the enrollee's specific benefit document supersedes this protocol. All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements and the plan benefit coverage prior to use of this Protocol. Other Protocols, Policies and Coverage Determination Guidelines may apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Protocols, Policies and Guidelines as necessary. This protocol is provided for informational purposes. It does not constitute medical advice. UnitedHealthcare may also use tools developed by third parties, such as the MCG Care Guidelines, to assist us in administering health benefits. The MCG Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. COMMERCIAL INDICATIONS FOR COVERAGE I. Varicose Vein Ablative and Stripping Procedures: A. Radiofrequency ablation, endovenous laser ablation, stripping, ligation and excision of the great saphenous vein and small saphenous veins are considered reconstructive and medically necessary when ALL of the following criteria are present (1, 2, 3 and 4): 1. Junctional Reflux (see definition section): a. Ablative therapy for the greater or small saphenous veins will be considered reconstructive and therefore medically necessary only if junctional reflux is demonstrated in these veins; OR Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 1 of 21

b. Ablative therapy for accessory veins will be considered reconstructive and medically necessary only if anatomically related persistent junctional reflux is demonstrated after the greater or small saphenous veins have been removed or ablated. 2. Member must have one of the following functional impairments: a. Skin ulceration OR b. Documented episode(s) of frank bleeding of the varicose vein due to erosion of /or trauma to the skin OR c. Documented superficial thrombophlebitis or documented venous stasis dermatitis OR d. Moderate to severe pain causing functional/physical impairment. 3. Venous Size: a. The greater saphenous vein must be 5.5mm or greater when measured at the proximal thigh immediately below the sapheno-femoral junction via duplex ultrasonography b. The small saphenous vein or accessory veins must measure 5 mm or greater in diameter immediately below the appropriate junction. 4. Duration of reflux, in the standing or reverse Trendelenburg position that meets the following parameters: a. Greater than or equal to 500 milliseconds (ms) for the great saphenous, small saphenous or principle tributaries b. Perforating veins > 350 ms c. Some duplex ultrasound readings will describe this as moderate to severe reflux which will be acceptable. B. Ablation of perforator veins is considered reconstructive and medically necessary when the following criteria are present: 1. Evidence of perforator venous insufficiency measured by recent duplex ultrasonography report (see criteria above) AND 2. Perforator vein size is 3.5mm or greater AND 3. Perforating vein lies beneath a healed or active venous stasis ulcer. C. Endomechanical ablation of varicose veins using a percutaneous infusion catheteris not medical necessary for treating venous reflux. There is insufficient evidence in the clinical literature supporting the safety and efficacy of endomechanical ablation for treating varicose veins. Further results from large, well-designed studies are needed to support the clinical utility of this approach. II. Ligation Procedures: A. Ligation of the great saphenous vein at the saphenofemoral junction, as a stand-alone procedure, is not medically necessary for treating venous reflux. Ligation performed without stripping or ablation is associated with high long-term recurrence rates due to neovascularization. B. Ligation of the small saphenous vein at the saphenopopliteal junction, as a stand-alone procedure, is not medically necessary for treating venous reflux. Ligation performed without Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 2 of 21

stripping or ablation is associated with high long-term recurrence rates due to neovascularization. C. Ligation at the saphenofemoral junction, as a stand-alone procedure, is medically necessary, when used to prevent the propagation of an active clot to the deep venous system in patients with ascending superficial thrombophlebitis who fail or are intolerant of anticoagulation therapy. D. Ligation at the saphenofemoral junction, as an adjunct to radiofrequency ablation or endovenous laser ablation of the main saphenous veins, is not medically necessary for treating venous reflux. Published clinical evidence has not demonstrated that the addition of saphenofemoral ligation to endovenous ablation procedures provides an additive benefit in resolving venous reflux or preventing varicose vein recurrence. Endovenous ablation is a clinically effective therapy for treating venous reflux. Adding ligation to the procedure adds clinical risk without adding clinical benefit. DEFINITIONS When applicable, please refer to the enrollee-specific plan document for definitions. Accessory/Tributary Vein: Axial accessory or tributary saphenous veins indicate any venous segment ascending parallel to the greater saphenous vein and located more superficially above the saphenous fascia, both in the leg and in the thigh. These can include the anterior accessory vein, the posteromedial vein, circumflex veins [anterior or posterior], intersaphenous veins, Giacomini vein or posterior [Leonardo] or anterior arch veins. Duplex Ultrasonography: Combines a real-time B mode scanner with built-in Doppler capability. The B mode scanner outlines anatomical structure while Doppler detects the flow, direction of flow and flow velocity. Endovenous Ablation: A minimally invasive procedure that uses heat generated by radiofrequency (RF) or laser energy to seal off damaged veins. Functional/Physical Impairment: A physical/functional or physiological impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life functions. Great Saphenous Vein: The GSV originates from the dorsal arch of the foot and progresses medially and proximally along the distal extremity to join the common femoral vein. High Quality Photograph: Ideally, a high-quality print should be in color have at least 200 pixels per inch. It must be detailed enough to show the patient s anatomy that is described in the physician s office notes If submitted as a hard copy, the image must be on photographic paper. Junctional Reflux: Reflux that exceeds a duration of 0.5 seconds at either: The confluence of the greater saphenous vein and the femoral vein Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 3 of 21

The confluence of the small saphenous vein and the popliteal vein Ligation: Tying off a vein. Reconstructive Procedures: Reconstructive procedures when the primary purpose of the procedure is either to treat a medical condition or to improve or restore physiologic function. Reconstructive procedures include surgery or other procedures which are associated with an Injury, Sickness or Congenital Anomaly. The primary result of the procedure is not a changed or improved physical appearance. Reticular Vein: Reticular veins are dilated dermal veins less than 4mm in diameter that communicate with either or both telangiectasia and saphenous tributaries. Small Saphenous Vein: Superficial vein of the calf. Spectral Doppler Flow Imaging: examines flow at one site provides a detailed analysis of distribution of flow provides good temporal resolution, capable of examining flow waveform allows for calculation of velocity and indices Spider Vein: Spider Veins/Telangiectasia are the permanent dilation of preexisting small blood vessels, generally up to 1mm in size. Stripping: Surgical removal of superficial veins Superficial Thrombophlebitis: Inflammation of a vein due to a blood clot in a vein just below the skin s surface. Telangiectasia: See spider vein. Varicose Veins: Abnormally enlarged veins that are frequently visible under the surface of the skin; often appear blue, bulging and twisted. Venous Reflux/Insufficiency: Venous reflux is reversed blood flow in the veins [away from the heart]. Abnormal [pathological reflux] is defined as reverse flow that lasts beyond a specified period of time as measured by Doppler ultrasound. Normal [physiological reflux] is defined as reverse flow that lasts less than a specified period of time as measured by Doppler ultrasound. Abnormal [pathological reflux] times exceed different thresholds depending on the system of veins: Deep veins: 1 sec Superficial veins: 0.5 sec Perforator veins: 0.35 sec Venous Stasis Dermatitis: A skin due to the chronic buildup of fluid (swelling) under the skin. Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 4 of 21

MEDICARE and MEDICAID RATIONALE Medicare does not have a National Coverage Determination for Varicose Vein Procedures. There is a Local Coverage Determination for Nevada for Treatment of Varicose Veins of the Lower Extremity (L33497) accessed March 2015. The Local Coverage Determination is as follows: Treatment of Varicose Veins of the Lower Extremity(L33497) Coverage Indications, Limitations and/or Medical Necessity Varicose veins are caused by venous insufficiency as a result of valve reflux (incompetence). The venous insufficiency results in dilated, tortuous, superficial vessels that protrude from the skin of the lower extremities. Spider veins (telangiectases) are dilated capillary veins that are most often treated for cosmetic purposes. Treatment of telangiectases (36468) is not covered by Medicare. Ligation and stripping of varicose veins is a treatment option that aims to eliminate reflux at the saphenofemoral junction. Some consider this the treatment of choice for moderate to large symptomatic varicose veins, ligation and stripping of the saphenous vein, has the lowest failure rate. Sclerotherapy, injecting sclerosing solutions directly into the abnormal veins, is an alternative occasionally selected for the treatment of varicose veins without significant saphenofemoral or saphenopopliteal incompetence. However, it is not considered to be as reliable and effective as surgical ligation and stripping. Sclerotherapy for cosmetic purposes is not considered medically necessary. Sclerotherapy is considered medically necessary for the treatment of small to medium sized vessels (generally less than 4 mm in diameter.) Sclerotherapy is not considered medically necessary for vessels larger than 5 mm in diameter. Foam sclerotherapy of the saphenous vein at its junction with the deep venous system has been proposed as an alternative to ligation or saphenectomy, but its efficacy lacks significant scientific evidence to support its widespread use. Sclerotherapy of the saphenous vein at its junction with the deep system is not a covered procedure. Non-compressive sclerotherapy involves injection of a sclerosant into a vein without the application of a compressive dressing. Because it is not effective in producing long-term obliteration of the incompetent veins, noncompressive sclerotherapy is not covered by Medicare. Compressive sclerotherapy is the injection of the sclerosant into an empty vein (elevated limb) followed by application of a compressive bandage or dressing. This is the most commonly performed sclerotherapy procedure for varicose veins of the lower extremity. Compressive sclerotherapy is indicated for local small to medium symptomatic varices, isolated incompetent perforators, or recurrence of symptomatic varices after adequate surgical removal of varices. It is not considered an appropriate option for large, extensive or truncal varicosities. High ligation and compression sclerotherapy refers to ligation of a truncal junction (saphenofemoral Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 5 of 21

or saphenopopliteal) followed by compressive sclerotherapy of one or more veins. Endovenous radiofrequency ablation (ERFA) and laser ablation are minimally invasive alternatives to vein ligation and stripping. Endovenous radiofrequency ablation is FDA-approved for treatment of the greater saphenous vein, perforators and tributary veins. Endovenous laser ablation is FDA-approved for the treatment of varicose veins and varicosities associated with superficial reflux of the greater saphenous vein. Stab phlebectomy or ambulatory phlebectomy may be considered medically necessary for treatment of patients who meet the medical necessity criteria listed below for varicose vein treatment whose symptoms and functional problems are attributable only to the secondary smaller vessels. Stab phlebectomy of the same vein performed on the same day as endovenous radiofrequency or laser ablation may be covered if the criteria for reasonable and necessary service are met and documentation in the chart supports the medical necessity. Indications: Medicare will consider interventional treatment of varicose veins (sclerotherapy, ligation with or without stripping, and endovenous radiofrequency or laser ablation) medically necessary if the patient remains symptomatic after a 6-8 week trial of conservative therapy. Based on recent literature combination therapy (the use of compression and surgery) has been shown to decrease 12 month ulcer recurrence rates and therefore may be considered in patients with chronic venous ulcers. Components of the conservative therapy include, but are not limited to: weight reduction, a daily exercise plan, periodic leg elevation, and the use of graduated compression stockings. The conservative therapy must be documented in the medical record. Conservative treatment may slow down progression of disease or may demonstrate (if symptoms reduced) that treating the disease may eliminate the symptoms. The patient is considered symptomatic if any of the following signs and symptoms of significantly diseased vessels of the lower extremities are documented in the medical record: stasis ulcer of the lower leg, as above, significant pain and/or significant edema that interferes with activities of daily living, bleeding associated with the diseased vessels of the lower extremities, recurrent episodes of superficial phlebitis, stasis dermatitis, or refractory dependent edema. Additional indications and limitations are discussed according to type of treatment. In addition to the requirement for failure of a 6-8 week trial of conservative treatment and the symptoms described above, coverage of endovenous ablation therapy is limited to patients with: laser ablation of veins with a vein diameter less than or equal to 20mm, or ERFA for a vein diameter less than or equal to 12mm, or Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 6 of 21

absence of thrombosis or vein tortuosity, which would impair catheter advancement, and absence of significant peripheral artery disease. Radiofrequency/laser ablation is covered only for treatment of the lesser or greater saphenous veins and selected tributaries to improve symptoms attributable to saphenofemoral or saphenopopliteal reflux. Coverage is only for FDA devices specifically approved for these procedures. Limitations: Duplex ultrasound is often used in conjunction with other non-invasive physiologic testing to define the anatomy and physiology of the varicose vein network prior to injection or surgical intervention. There is adequate evidence that the pre-procedural ultrasound is helpful, and Medicare will cover a pre-procedure Duplex scan (93970 or 93971) used in conjunction with other non-invasive physiologic testing (93965) to determine the extent and configuration of the varicosities. This A/B MAC expects that these studies will be performed by the provider planning to provide the therapy. This A/B MAC will allow this study once per provider or provider group. Clinical experience supports the use of ultrasound during the sclerotherapy procedure, and evidence shows that the outcomes may be improved and complication rates may be minimized when ultrasound guidance is used. Medicare will cover intraoperative ultrasonic guidance in situations when it is medically necessary. Medicare includes payment for the intraoperative ultrasound in the payment for the ERFA and laser ablation procedures. A postoperative ultrasound will be covered if the test is reasonable and necessary for the diagnosis and treatment of a complication. Cosmetic surgery is statutorily excluded from coverage by Medicare. The following interventional treatments are considered to be cosmetic and are denied as not medically necessary: Interventional treatment of asymptomatic varicosities. Treatment of telangiectases (36468). Sclerotherapy for cosmetic purposes. Medicare 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. The following interventional treatments are not considered medically reasonable or necessary and are denied as such: Interventional treatment of symptomatic varicosities without documentation of a failed 6-8 week trial of conservative therapy in patients without chronic venous ulcers. Sclerotherapy for vessels larger than 5 mm in diameter. Reinjection following recanalization or failure of vein closure without recurrent signs or symptoms. Sclerotherapy of the saphenous vein at its junction with the deep venous system. Noncompressive sclerotherapy. Compressive sclerotherapy for large, extensive or truncal varicosities. 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 bandages or stockings; severe distal arterial occlusive disease; obliteration of deep venous system; an allergy to the sclerosant; or a hypercoaguable state. Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 7 of 21

Any interventional treatment that uses equipment not approved for such purposes by the FDA. Laser ablation of veins with a diameter less than or equal to 20mm and ERFA for vein diameter less than or equal to 12mm. Endovenous ablation therapy in the presence of thrombosis or venous tortuosity which would impair catheter advancement. Documentation Requirements The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. 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 A/B MAC upon request for review. Utilization Guidelines 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 ERFA to check for any evidence of thrombus extension from the saphenofemoral junction into the deep system. For Medicare and Medicaid Determinations Related to States Outside of Nevada: Please review Local Coverage Determinations that apply to other states outside of Nevada. Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 8 of 21

http://www.cms.hhs.gov/mcd/search Important Note: Please also review local carrier Web sites in addition to the Medicare Coverage database on the Centers for Medicare and Medicaid Services Website. DESCRIPTION OF SERVICES Varicose veins are enlarged veins that are swollen and raised above the surface of the skin. They can be dark purple or blue, and look twisted and bulging. Varicose veins are commonly found on the backs of the calves or on the inside of the leg. Veins have one-way valves that help keep blood flowing towards the heart. When the valves become weak or damaged and do not close properly, blood can back up and pool in the veins causing them to get larger. The resulting condition is known as venous insufficiency or venous reflux. Varicose veins may lead to complications such as pain, blood clots or skin ulcers. Varicose veins are treated with lifestyle changes and medical procedures done either to remove the veins or to close them. Sclerotherapy uses a liquid chemical to close off a varicose vein. Endovenous ablation therapy uses lasers or radiofrequency energy to create heat to close off a varicose vein. Vein stripping and ligation involves tying shut and removing the veins through small cuts in the skin (National Heart, Lung and Blood Institute, 2011). Endomechanical ablation uses a specialized, rotating catheter (e.g., ClariVein) to close off a varicose vein by damaging the vessel lining prior to injecting a sclerosing agent. This technique is also referred to as mechanical occlusion-chemically assisted (MOCA), mechanico-chemical endovenous ablation (MCEA) and mechanically enhanced endovenous chemical ablation (MEECA). CLINICAL EVIDENCE O Hare et al. (2008) conducted a multicenter, prospective cohort study of patients undergoing small saphenous vein surgery (SSV). Patients were evaluated at six weeks and one year after surgery. A total of 204 legs were reviewed at one year; 67 had small saphenous varicose vein stripping, 116 had saphenopopliteal junction (SPJ) disconnection only and the remainder had miscellaneous procedures. The incidence of visible recurrent varicosities at one year was lower after SSV stripping than after disconnection only, although this did not reach statistical significance. The rate of SPJ incompetence detected by duplex at one year was significantly lower in patients who underwent SSV stripping than in those who did not. In a literature review of long-term results following high ligation supplemented by sclerotherapy, Recek (2004) found that ligation of the saphenofemoral junction alone provokes a higher recurrence rate in comparison with high ligation and stripping. The hemodynamic improvement achieved immediately after high ligation deteriorates progressively during the follow-up owing to recurrent reflux. Wichers et al. (2005) performed a systematic review of randomized trials evaluating the safety and efficacy of medical (anticoagulants) or surgical (ligation or stripping of the affected veins) treatments of superficial vein thrombosis (SVT) for the prevention of deep vein thrombosis (DVT) and pulmonary Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 9 of 21

embolism (PE). Five studies were included. Pooling of the data was not possible due to the heterogeneity among the studies. Three studies had major methodological drawbacks limiting the clinical applicability of the results. One of the remaining (pilot) studies showed a nonsignificant trend in favor of high-compared to low-dose unfractionated heparin for the prevention of venous thromboembolism (VTE). The last remaining study showed a non-significant trend in favor of shortterm treatment with low-molecular-weight heparin (LMWH) or a non-steroidal anti-inflammatory drug (NSAID) as compared to placebo shortly after treatment with respect to VTE, but the apparent benefit disappeared after three months of follow-up. More randomized controlled trials are needed before any evidence-based recommendations on the treatment of SVT for the prevention of VTE can be given. With the lack of solid evidence, the authors suggest treating patients with at least intermediate doses of LMWH. Surgical treatment of SVT may be considered when varicose veins are involved. Sullivan et al. (2001) performed a systematic review of the literature evaluating surgical and medical management of above-knee superficial thrombophlebitis (AK-STP) not involving the deep venous system. Six studies were included for a total of 246 patients in the surgical arm and 88 patients in the medical arm. Surgical treatment modalities halt the progression of thrombus into the deep venous system through the saphenofemoral junction and reduce the incidence of PE. The two types of surgical treatment were ligation of the greater saphenous vein at the saphenofemoral junction or ligation in combination with stripping of the phlebitic vein. Medical therapy consisted of initial intravenous heparin followed by warfarin therapy for a duration varying between 6 weeks and 6 months. The authors offered no definitive conclusions due to reporting of varied outcomes, different follow-up criteria and the retrospective nature of the studies. The differences between the surgical and medical groups were small. The review concludes that medical management with anticoagulants is superior for minimizing complications and preventing subsequent deep vein thrombosis and pulmonary embolism development as compared to surgical treatment with ligation of the greater saphenous vein at the saphenofemoral junction or ligation and stripping. Winterborn et al. (2004) conducted an 11 year follow-up study on the Jones et al. patient group. A cumulative total of 83 legs had developed clinically recurrent varicose veins by 11 years (62%). There was no statistically significant difference between the ligation-only and the stripping groups. Reoperation was required for 20 of 69 legs that underwent ligation alone compared with 7 of 64 legs that had additional long saphenous vein stripping. Freedom from reoperation at 11 years was 70% after ligation, compared with 86% after stripping. The presence of neovascularization, an incompetent superficial vessel in the thigh or an incompetent saphenofemoral junction on duplex imaging at 2 years postoperatively increased the risk of a patient's developing clinically recurrent veins. Results from the study indicate that stripping the long saphenous vein is recommended as part of routine varicose vein surgery as it reduces the risk of reoperation after 11 years, although it did not reduce the rate of visible recurrent veins. Dwerryhouse et al. (1999) designed as a 5-year follow-up study on the Jones et al. patient group. 78 patients (110 legs) underwent clinical review and duplex scan imaging. Sixty-five patients remained pleased with the results of their surgery (35 of 39 stripped vs. 30 of 39 ligated). Reoperation for recurrence was necessary for three of 52 of the legs that underwent stripping vs. 12 of 58 ligated legs. Neovascularization at the saphenofemoral junction was responsible for 10 of 12 recurrent veins that underwent reoperation and also was the cause of recurrent saphenofemoral incompetence in 12 of 52 stripped veins vs. 30 of 58 ligated legs. The authors concluded that stripping reduced the risk of Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 10 of 21

reoperation by two thirds after 5 years and should be routine for primary long saphenous varicose veins. Jones et al. (1996) conducted a randomized controlled trial of one hundred patients (133 legs) to determine whether routine stripping of the long saphenous vein reduced recurrence after varicose vein surgery. A two year follow-up in 81 patients (113 legs) showed that 89% of patients remained satisfied with the results of their surgery, though 35% had recurrent veins on clinical examination. Recurrence was reduced in patients who had their long saphenous vein stripped. Neovascularization was detected in 52% of limbs and was the most common cause of recurrence. Rutgers et al. (1994) conducted a prospective randomized study comparing stripping and local avulsions with high ligation of the saphenofemoral junction combined with sclerotherapy for the treatment of greater saphenous vein insufficiency. Of 156 consecutive patients, 89 legs were randomly allocated to stripping and 92 to high ligation. Patients were followed-up at 3 months and 1, 2, and 3 years after treatment. At 3 years, 69 limbs in the stripping group (78%) and 73 limbs in the ligation group (79%) were available to follow-up. The authors found that clinical and Doppler ultrasound evidence of reverse flow in the saphenous vein was significantly less after stripping. Eighty-nine legs with long saphenous vein (LSV) reflux and saphenofemoral junction incompetence were treated by saphenofemoral ligation and multiple avulsions. Patients were randomized to undergo additional stripping of the LSV (n = 43) or no additional treatment (n = 46). At a median of 21 months after surgery, more patients were free of recurrence when the LSV had been stripped compared with saphenofemoral ligation alone. The authors concluded that the addition of LSV stripping to saphenofemoral ligation and multiple avulsions results in a better overall outcome (Sarin, 1994). During endovenous ablation procedures, radiofrequency or laser energy is applied to heat the vein, causing the vessel to close and eventually be absorbed by the body. This technique achieves the same effect as saphenofemoral or saphenopopliteal ligation and stripping. Adding ligation of the main trunk to the procedure has not been shown to provide an additive benefit in resolving venous reflux or preventing varicose vein recurrence. In a systematic review, Darwood and Gough found that adjunctive saphenofemoral ligation is not necessary to achieve success with endovenous laser therapy of the greater saphenous vein (Darwood, 2009). Similarly, a randomized controlled trial conducted by Disselhoff et al. (2008) found that the addition of saphenofemoral ligation to endovenous ablation made no difference to the short-term outcome of varicose vein treatment. Long-term follow-up at 5 years found similar results (Disselhoff et al. 2011). Further studies with larger patient populations are needed to establish the superiority of adjunctive saphenofemoral ligation in improving long-term outcomes. Theivacumar et al. (2007) also found that saphenofemoral ligation following endovenous laser ablation was unnecessary. Persistent non-refluxing greater saphenous vein tributaries at the saphenofemoral junction did not have an adverse impact on clinical outcome 1 year after successful endovenous laser ablation of the greater saphenous vein. Endomechanical AblationBootun et al. (2014) compared pain scores in patients treated for primary varicose veins. A total of 119 patients were randomized to mechanochemical ablation (n=60) or Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 11 of 21

radiofrequency ablation (n=59). Maximum pain score was significantly lower in the mechanochemical ablation group compared to the radiofrequency ablation group. Average pain score was also significantly lower in the mechanochemical ablation group compared to the radiofrequency ablation group. Sixty-six percent attended follow-up at one month, and the complete or proximal occlusion rates were 92% for both groups. At one month, the clinical and quality of life scores for both groups had similar improvements. The long-term data including occlusion rates at six months and quality of life scores are being collected. Bishawi at al. (2013) conducted a prospective observational multicenter study on the efficacy of mechanochemical ablation (MOCA) in patients with lower extremity chronic venous disease. A total of 126 patients were included at baseline, 81% females. The mean diameter of the great saphenous vein in the upper thigh was 7.3mm and the mean treatment length was 38cm. Adjunctive treatment was performed in 11% of patients during the procedure. Closure rates were 100% at one week, 98% at three months and 94% at six months. Post-procedure complications included hematoma, ecchymosis and thrombophlebitis. There were no cases of venous thromboembolism. The authors concluded that MOCA of the saphenous veins has the advantage of endovenous ablation without tumescent anesthesia. This study is limited by lack of randomization and control and short-term follow-up. In a prospective comparison study, van Eekeren et al. (2013) evaluated postoperative pain and quality of life after radiofrequency ablation (RFA) and mechanochemical endovenous ablation (MOCA) for great saphenous vein (GSV) incompetence. Sixty-eight patients with unilateral GSV incompetence were included. Patients treated with MOCA reported significantly less postoperative pain than patients treated with RFA during the first 14 days after treatment. The lower postoperative pain score was associated with a significantly earlier return to normal activities and work. At 6 weeks, patients in both groups perceived an improved change in health status and an improved disease-specific quality of life. This study is limited by lack of randomization and control, small sample size and short-term follow-up. In a prospective cohort study, Boersma et al. (2013) evaluated the feasibility, safety and 1-year results of mechanochemical endovenous ablation (MOCA) of small saphenous vein (SSV) insufficiency. Fifty consecutive patients were treated using the ClariVein device and polidocanol. At the 6-week assessment, all treated veins were occluded. One-year follow-up showed a 94% anatomic success rate and no major complications. The authors concluded that MOCA is a safe, feasible and efficacious technique for treating SSV insufficiency. This study is limited by lack of randomization and control, small sample size and short-term follow-up. Elias and Raines (2012) assessed the safety and efficacy of the ClariVein system for mechanochemical ablation of the great saphenous vein (GSV). Thirty GSVs in 29 patients were treated. At six-month follow-up, the primary closure rate was 96.7% with no adverse events reported. The authors concluded that mechanochemical ablation appears to be safe and efficacious. This study is limited by lack of randomization and control, small sample size and short-term follow-up. In a pilot study, Van Eekeren et al. (2011) evaluated the feasibility and safety of endovenous mechanochemical ablation (MOCA) for the treatment of greater saphenous vein (GSV) incompetence. Thirty limbs in 25 patients (18 women; mean age 52 years) with GSV incompetence were treated with the ClariVein device. Initial technical success, complications, patient satisfaction and classification by venous clinical severity score (VCSS) were assessed 6 weeks after the treatment. Initial technical Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 12 of 21

success of MOCA was 100%. There were no major adverse events. Duplex ultrasonography at 6 weeks showed 26 (87%) of 30 veins were completely occluded. Three veins showed partial recanalization in the proximal and distal GSV. One patient had full segment recanalization and was successfully retreated. The VCSS significantly improved at 6 weeks. Patient satisfaction was high, with a median satisfaction of 8.8 on a 0-10 scale. The authors concluded that endovenous MOCA is feasible and safe in the treatment of GSV incompetence. Larger studies with a prolonged follow-up are indicated to prove the efficacy of this technique. A National Institute for Health and Care Excellence (NICE) guideline states that current evidence on the safety and efficacy of endovenous mechanochemical ablation for varicose veins is inadequate in quantity and quality. This procedure should only be used with special arrangements for clinical governance, consent and audit or research. This procedure should only be carried out by clinicians with specific training in this technique (NICE, 2013). Professional Societies Society for Vascular Surgery (SVS)/American Venous Forum (AVF) The SVS and AVF released joint clinical practice guidelines regarding the care of patients with varicose veins (Gloviczki et al., 2011). The policy states that patients who undergo high ligation alone of the great saphenous vein (GSV) have recurrent reflux in the residual GSV. This causes new symptoms and increases the risk of reoperation. U.S. FOOD AND DRUG ADMINISTRATION (FDA) Vein ligation surgery is a procedure and therefore not subject to FDA regulation. The ClariVein infusion catheter (Vascular Insights) received FDA approval (K071468) on March 20, 2008. The device is designed to introduce physician-specified medicaments into the peripheral vasculature. See the following website for more information: http://www.accessdata.fda.gov/cdrh_docs/pdf7/k071468.pdf. Accessed March 2015 APPLICABLE CODES The Current Procedural Terminology (CPT ) codes and Healthcare Common Procedure Coding System (HCPCS) codes listed in this policy are for reference purposes only. Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the enrollee specific benefit document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Other policies and coverage determination guidelines may apply. This list of codes may not be all inclusive. HCPCS Code S2202 Description Echosclerotherapy CPT Codes Description 36475 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 13 of 21

imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and 36476 subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) Endovenous ablation therapy of incompetent vein, extremity, inclusive of all 36478 imaging guidance and monitoring, percutaneous, laser; first vein treated Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and 36479 subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) Ligation and division of long saphenous vein at saphenofemoral junction, or 37700 distal interruptions 37718 Ligation, division, and stripping, short saphenous vein Ligation, division, and stripping, long (greater) saphenous veins from 37722 saphenofemoral junction to knee or below Ligation and division of short saphenous vein at saphenopopliteal junction 37780 (separate procedure). 37799 Unlisted procedure, vascular surgery CPT is a registered trademark of the American Medical Association. NOTE: According to the American Medical Association (AMA), CPT code 37241 is specific to venous embolization/occlusion and excludes lower extremity venous incompetency. Coding instructions state that 37241 should not be used to report treatment of incompetent extremity veins (CPT Assistant, 2014). ICD-9 Codes Description 451.0 Phlebitis and thrombophlebitis of superficial vessels of lower extremities 451.11 Phlebitis and thrombophlebitis of femoral vein (deep) (superficial) 451.2 Phlebitis and thrombophlebitis of lower extremities, unspecified 454.0 Varicose veins of lower extremities with ulcer 454.1 Varicose veins of lower extremities with 454.2 Varicose veins of lower extremities with ulcer and 454.8 Varicose veins of the lower extremities with other complications 459.81 Unspecified venous (peripheral) insufficiency Coding Clarification Simple sclerotherapy procedures should not be reported with transcatheter codes. ICD-10 Codes (Preview Draft) In preparation for the transition from ICD-9 to ICD-10 medical coding on October 1, 2015*, a sample listing of the ICD-10 CM and/or ICD-10 PCS codes associated with this policy has been provided below for your reference. This list of codes may not be all inclusive and will be updated to reflect any applicable revisions to the ICD-10 code set and/or clinical guidelines outlined in this policy. *The effective date for ICD-10 code set implementation is subject to change. Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 14 of 21

ICD-10 Diagnosis Description Codes (Effective 10/01/15) Phlebitis and thrombophlebitis of superficial vessels of unspecified lower 180.00 extremity 180.01 Phlebitis and thrombophlebitis of superficial vessels of right lower extremity 180.02 Phlebitis and thrombophlebitis of superficial vessels of left lower extremity 180.03 Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateral 180.10 Phlebitis and thrombophlebitis of unspecified femoral vein 180.11 Phlebitis and thrombophlebitis of right femoral vein 180.12 Phlebitis and thrombophlebitis of left femoral vein 180.13 Phlebitis and thrombophlebitis of femoral vein, bilateral 180.3 Phlebitis and thrombophlebitis of lower extremities, unspecified 183.001 Varicose veins of unspecified lower extremity with ulcer of thigh 183.002 Varicose veins of unspecified lower extremity with ulcer of calf 183.003 Varicose veins of unspecified lower extremity with ulcer of ankle 183.004 Varicose veins of unspecified lower extremity with ulcer of heel and midfoot 183.005 Varicose veins of unspecified lower extremity with ulcer other part of foot 183.008 Varicose veins of unspecified lower extremity with ulcer other part of lower leg 183.009 Varicose veins of unspecified lower extremity with ulcer of unspecified site 183.011 Varicose veins of right lower extremity with ulcer of thigh 183.012 Varicose veins of right lower extremity with ulcer of calf 183.013 Varicose veins of right lower extremity with ulcer of ankle 183.014 Varicose veins of right lower extremity with ulcer of heel and midfoot 183.015 Varicose veins of right lower extremity with ulcer other part of foot 183.018 Varicose veins of right lower extremity with ulcer other part of lower leg 183.019 Varicose veins of right lower extremity with ulcer of unspecified site 183.021 Varicose veins of left lower extremity with ulcer of thigh 183.022 Varicose veins of left lower extremity with ulcer of calf 183.023 Varicose veins of left lower extremity with ulcer of ankle 183.024 Varicose veins of left lower extremity with ulcer of heel and midfoot 183.025 Varicose veins of left lower extremity with ulcer other part of foot 183.028 Varicose veins of left lower extremity with ulcer other part of lower leg 183.029 Varicose veins of left lower extremity with ulcer of unspecified site 183.10 Varicose veins of unspecified lower extremity with 183.11 Varicose veins of right lower extremity with 183.12 Varicose veins of left lower extremity with 183.201 Varicose veins of unspecified lower extremity with both ulcer of thigh and 283.202 Varicose veins of unspecified lower extremity with both ulcer of calf and 183.203 Varicose veins of unspecified lower extremity with both ulcer of ankle and Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 15 of 21

183.204 Varicose veins of unspecified lower extremity with both ulcer of heel and midfoot and 183.205 Varicose veins of unspecified lower extremity with both ulcer other part of foot and 183.208 Varicose veins of unspecified lower extremity with both ulcer of other part of lower extremity and 183.209 Varicose veins of unspecified lower extremity with both ulcer of unspecified site and 183.211 Varicose veins of right lower extremity with both ulcer of thigh and 183.212 Varicose veins of right lower extremity with both ulcer of calf and 183.213 Varicose veins of right lower extremity with both ulcer of ankle and 183.214 Varicose veins of right lower extremity with both ulcer of heel and midfoot and 183.215 Varicose veins of right lower extremity with both ulcer other part of foot and 183.218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and 183.219 Varicose veins of right lower extremity with both ulcer of unspecified site and 183.221 Varicose veins of left lower extremity with both ulcer of thigh and 183.222 Varicose veins of left lower extremity with both ulcer of calf and 183.223 Varicose veins of left lower extremity with both ulcer of ankle and 183.224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and 283.225 Varicose veins of left lower extremity with both ulcer other part of foot and 183.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and 183.229 Varicose veins of left lower extremity with both ulcer of unspecified site and 183.811 Varicose veins of right lower extremities with pain 183.812 Varicose veins of left lower extremities with pain 183.813 Varicose veins of bilateral lower extremities with pain 183.819 Varicose veins of unspecified lower extremities with pain 183.891 Varicose veins of right lower extremities with other complications 183.892 Varicose veins of left lower extremities with other complications 183.893 Varicose veins of bilateral lower extremities with other complications 183.899 Varicose veins of unspecified lower extremities with other complications Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 16 of 21

187.2 Venous insufficiency (chronic) (peripheral) 187.9 Disorder of vein, unspecified REFERENCES Allan PL. Role of ultrasound in the assessment of chronic venous insufficiency. Ultrasound Q. 2001 Mar;17(1):3-10. American Medical Association. Current Procedural Terminology: CPT Professional Edition. AMA Press. Bishawi M, Bernstein R, Boter M, et al. Mechanochemical ablation in patients with chronic venous disease: A prospective multicenter report. Phlebology. 2013 Jul 2. [Epub ahead of print] Boersma D, van Eekeren RR, Werson DA, et al. Mechanochemical endovenous ablation of small saphenous vein insufficiency using the ClariVein device: one-year results of a prospective series. Eur J Vasc Endovasc Surg. 2013 Mar;45(3):299-303. Bootun R, Lane T, Dharmarajah B, et al. Intra-procedural pain score in a randomized controlled trial comparing mechanochemical ablation to radiofrequency ablation: The Multicentre Venefit versus ClariVein for varicose veins trial. Phlebology. 2014 Sep 5. Pii:0268355514551085. [Epub ahead of print] Chaar CI, Hirsch SA, Cwenar MT, et al. Expanding the role of endovenous laser therapy: results in large diameter saphenous, small saphenous, and anterior accessory veins. Ann Vasc Surg. 2011;25(5):656-61. Chandler JG, Pichot O, Sessa C, et al. Defining the role of extended saphenofemoral junction ligation: A prospective comparative study.j Vasc Surg. 2000;32(5):941-953. ClariVein website. http://clarivein.eu/home. Accessed March 2015. CPT Assistant. Correct coding of endovascular treatment for low extremity venous incompetency. October 2014. Darwood RJ, Gough MJ. Endovenous laser treatment for uncomplicated varicose veins. Phlebology. 2009;24 Suppl 1:50-61. Disselhoff BC, der Kinderen DJ, Kelder JC, Moll FL. Randomized clinical trial comparing endovenous laser ablation of the great saphenous vein with and without ligation of the saphenofemoral junction: 2-year results. Eur J Vasc Endovasc Surg. 2008 Dec;36(6):713-8. Disselhoff BC, der Kinderen DJ, Kelder JC, Moll FL. Five-year results of a randomised clinical trial of endovenous laser ablation of the great saphenous vein with and without ligation of the saphenofemoral junction. Eur J Vasc Endovasc Surg. 2011 May;41(5):685-90. Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 17 of 21

Dwerryhouse S, Davies B, Harradine K, Earnshaw JJ. Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: five-year results of a randomized trial. J Vasc Surg. 1999 Apr;29(4):589-92. Eklof B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classification of chronic venous disorders: Consensus statement. Journal of Vascular Surgery. 2004; 40:1248-1252. Elias S, Raines JK. Mechanochemical tumescentless endovenous ablation: final results of the initial clinical trial. Phlebology. 2012 Mar;27(2):67-72. Engelhorn C, Engelhorn A, et al Relationship Between Reflux and Greater Saphenous Vein Diameter. Journal of Vascular Technology 1997;21(3):167-172 Gloviczki P, Comerota AJ, Dalsing MC, et al.; Society for Vascular Surgery; American Venous Forum. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011 May;53(5 Suppl):2S-48S. Goren G, Yellin AE. Primary varicose veins: topographic and hemodynamic correlations. J Cardiovasc Surg (Torino) 1990; 31(5):672-7. Hayes, Inc. Search and Summary. Clarivein occlusion catheter, non-thermal vein ablation system (Vascular Insights LLC) for varicose veins. November 2013. Archived December 2014. Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL). 2007 ICAVL Standards. Part II: Vascular Laboratory Operations Peripheral Venous. Jones L, Braithwaite BD, Selwyn D, et al. Neovascularisation is the principal cause of varicose vein recurrence: results of a randomised trial of stripping the long saphenous vein. Eur J Vasc Endovasc Surg. 1996 Nov;12(4):442-5.. Kontothanassis D, Di Mitri R, Ferrari Ruffino S, et al. Endovenous laser treatment of the small saphenous vein. J Vasc Surg. 2009;49(4):973-979. Labropoulos N, Kang SS, Mansour MA, et al. Primary superficial vein reflux with competent saphenous trunk. Eur J Vasc Endovasc Surg. 1999 Sep;18(3):201-6. Labropoulos N, Kokkosis AA, Spentzouris G, et al. The distribution and significance of varicosities in the saphenous trunks. J Vasc Surg. 2010 Jan;51(1):96-103. Labropoulos N, Leon L. Sapheno-femoral junction reflux in patients with a normal saphenous trunk. Eur J Vasc Endovasc Surg. 2004 Dec;28(6):595-9. Labropoulos N, Tiongson J, Pryor L, et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg. 2003 Oct;38(4):793-8. Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 18 of 21

Marston WA, Owens LV, Davies S, et al. Endovenous saphenous ablation corrects the hemodynamic abnormality in patients with CEAP clinical class 3-6 CVI due to superficial reflux. Vasc Endovascular Surg. 2006 Mar-Apr;40(2):125-30. Medical Advisory Secretariat. Endovascular radiofrequency ablation for varicose veins: an evidence-based analysis. Ont Health Technol Assess Ser. 2011;11(1):1-93. Available at: http://www.health.gov.on.ca/english/providers/program/mas/tech/reviews/pdf/rev_rfa_vv_20110216.p df Accessed March 2015. Meissner MH. Lower extremity venous anatomy. Semin Intervent Radiol. 2005 Sep;22(3):147-56. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3036282/pdf/sir22147.pdf. Accessed March 2015. Merchant RF, Pichot O. Closure Study Group. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg. 2005 Sep;42(3):502-9. National Heart, Lung and Blood Institute (NHLBI) website. Varicose veins. February 2011. Available at: http://www.nhlbi.nih.gov/health/dci/diseases/vv/vv_whatis.html. Accessed March 2015 National Institute for Health and Care Excellence (NICE). IPG 435. Endovenous mechanochemical ablation for varicose veins. January 2013. Available at: http://www.nice.org.uk/guidance/ipg435. Accessed March 2015 Navarro et al: Clinical and Hemodynamic Significance of the Greater Saphenous Vein Diameter in Chronic Venous Insufficiency. Arch Surg. 2002 Nov;137(11):1233-7. O'Hare JL, Vandenbroeck CP, Whitman B, et al. A prospective evaluation of the outcome after small saphenous varicose vein surgery with one-year follow-up. J Vasc Surg. 2008 Sep;48(3):669-73; discussion 674. Proebstle TM, Gül D, Lehr HA, et al. Infrequent early recanalization of greater saphenous vein after endovenous laser treatment. J Vasc Surg. 2003; 38(3):511-6. Recek C. Saphenofemoral junction ligation supplemented by postoperative sclerotherapy: a review of long-term clinical and hemodynamic results. Vasc Endovascular Surg. 2004 Nov-Dec;38(6):533-40. Rohren E, Kliewer M, Carroll B, et al. A Spectrum of Doppler Waveforms in the Carotid and Vertebral Arteries. American Journal of Roentgenology. 2003 Dec.; 181: 1695-1704. Rutgers PH, Kitslaar PJ. Randomized trial of stripping versus high ligation combined with sclerotherapy in the treatment of the incompetent greater saphenous vein. Am J Surg. 1994 Oct;168(4):311-5. Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 19 of 21

Sarin S, Scurr JH, Coleridge Smith PD. Stripping of the long saphenous vein in the treatment of primary varicose veins. Br J Surg. 1994 Oct;81(10):1455-8. Sullivan V, Denk PM, Sonnad SS, et al. Ligation versus anticoagulation: treatment of above-knee superficial thrombophlebitis not involving the deep venous system. J Am Coll Surg. 2001 Nov;193(5):556-62. Theivacumar NS, Dellagrammaticas D, Beale RJ, et al. Fate and clinical significance of saphenofemoral junction tributaries following endovenous laser ablation of great saphenous vein. Br J Surg. 2007 Jun;94(6):722-5. Theivacumar NS, Darwood RJ, Gough MJ. Endovenous laser ablation (EVLA) of the anterior accessory great saphenous vein (AAGSV): abolition of sapheno-femoral reflux with preservation of the great saphenous vein. Eur J Vasc Endovasc Surg. 2009 Apr;37(4):477-81. Theivacumar NS, Dellagrammaticas D, Mavor AI, et al. Endovenous laser ablation: does standard above-knee great saphenous vein ablation provide optimum results in patients with both above- and below-knee reflux? A randomized controlled trial. J Vasc Surg. 2008 Jul;48(1):173-8. Theivacumar NS, Dellagrammaticas D, Mavor AI, et al. Endovenous laser ablation (EVLA) of great saphenous vein to abolish "paradoxical reflux" in the Giacomini vein: a short report. Eur J Vasc Endovasc Surg. 2007 Aug;34(2):229-31. Theivacumar NS, Gough MJ. Endovenous laser ablation (EVLA) to treat recurrent varicose veins. Eur J Vasc Endovasc Surg. 2011 May; 41(5):691-6. van Eekeren RR, Boersma D, Konijn V, et al. Postoperative pain and early quality of life after radiofrequency ablation and mechanochemical endovenous ablation of incompetent great saphenous veins. J Vasc Surg. 2013 Feb;57(2):445-50. van Eekeren RR, Boersma D, Elias S, et al. Endovenous mechanochemical ablation of great saphenous vein incompetence using the ClariVein device: a safety study. J Endovasc Ther. 2011 Jun;18(3):328-34. Wichers IM, Di Nisio M, Büller HR, Middeldorp S. Treatment of superficial vein thrombosis to prevent deep vein thrombosis and pulmonary embolism: a systematic review. Haematologica. 2005 May;90(5):672-7. Winterborn, RJ, et al. (2004). Causes of varicose vein recurrence: late results of a randomized controlled trial of stripping the long saphenous vein. J Vasc Surgery. 40(4): 634-9. Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 20 of 21

PROTOCOL HISTORY/REVISION INFORMATION Date 03/26/2015 05/22/2014 3/27/2014 1/23/2014 10/24/2013 05/23/2013 04/25/2013 06/28/2012 07/28/2011 03/24/2011 01/28/2011 11/2010 07/13/2010 04/23/2010 07/24/2009 Action/Description Corporate Medical Affairs Committee The foregoing Health Plan of Nevada/Sierra Health & Life Operations protocol has been adopted from an existing UnitedHealthcare coverage determination guideline that was researched, developed and approved by the UnitedHealthcare Coverage Determination Committee. Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Page 21 of 21