BlueAdvantage Administrators of Arkansas
Coverage Policy#: 761
Category: Surgery
Initiated: January 2010
Last Review: February 23, 2026
Last Revision: February 23, 2026
BlueAdvantage National Accounts
Coverage Policy for Participants and Beneficiaries enrolled in Walmart Associates' Health and Welfare Medical Plan
(Developed by BlueAdvantage Administrators and Adopted by the Walmart Plan as Plan Coverage Criteria)

Treatment of Varicose Veins/Venous Insufficiency

Description:
A variety of treatment modalities are available to treat varicose veins/venous insufficiency, including surgical approaches, thermal ablation, and sclerotherapy. The application of each of these treatment options is influenced by the severity of the symptoms, type of vein, source of venous reflux, and the use of other (prior or concurrent) treatments.
 
The venous system of the lower extremities consists of the superficial veins (this includes the greater and lesser saphenous and accessory, or duplicate, veins that travel in parallel with the greater and lesser saphenous veins), the deep system (popliteal and femoral veins), and perforator veins that cross through the fascia and connect the deep and superficial systems. One-way valves are present within all veins to direct the return of blood up the lower limb. Since venous pressure in the deep system is generally greater than that of the superficial system, valve incompetence at any level may lead to backflow (venous reflux) with pooling of blood in superficial veins. Varicose veins with visible varicosities may be the only sign of venous reflux, although itching, heaviness, tension, and pain may also occur. Chronic venous insufficiency secondary to venous reflux can lead to thrombophlebitis, leg ulcerations, and hemorrhage. The CEAP classification considers the clinical, etiologic, anatomic, and pathologic (CEAP) characteristics of venous insufficiency, ranging from class 0 (no visible sign of disease) to class 6 (active ulceration).
 
Treatment of venous reflux/venous insufficiency is aimed at reducing abnormal pressure transmission from the deep to the superficial veins. Conservative medical treatment consists of elevation of the extremities, graded compression, and wound care when indicated. Conventional surgical treatment consists of identifying and correcting the site of reflux by ligation of the incompetent junction followed by stripping of the vein to redirect venous flow through veins with intact valves. While most venous reflux is secondary to incompetent valves at the saphenofemoral or saphenopopliteal junctions, reflux may also occur at incompetent valves in the perforator veins or in the deep venous system. The competence of any single valve is not static and may be pressure-dependent. For example, accessory saphenous veins may have independent saphenofemoral or saphenopopliteal junctions that become incompetent when the greater or lesser saphenous veins are eliminated and blood flow is diverted through the accessory veins.
 
Saphenous Veins and Tributaries
Saphenous veins include the greater and lesser saphenous and accessory saphenous veins that travel in parallel with the greater or lesser saphenous veins. Tributaries are veins that empty into a larger vein. Treatment of venous reflux typically includes the following:
 
  1.   Identification by preoperative Doppler ultrasonography of the valvular incompetence;
  2.   Control of the most proximal point of reflux, traditionally by suture ligation of the incompetent saphenofemoral or saphenopopliteal junction;   
  3.    Removal of the superficial vein from circulation, for example by stripping of the greater and/or lesser saphenous veins;
  4.    Removal of varicose tributaries (at the time of the initial treatment or subsequently) by stab avulsion (phlebectomy) or injection sclerotherapy.
 
Minimally invasive alternatives to ligation and stripping have been investigated. These include sclerotherapy, transilluminated-powered phlebotomy, and thermal ablation using cryotherapy, high frequency radiowaves (200–300 kHz), or laser energy.
 
Sclerotherapy
The objective of sclerotherapy is to destroy the endothelium of the target vessel by injecting an irritant solution (either a detergent, osmotic solution, or chemical irritant), ultimately resulting in the occlusion of the vessel. The success of the treatment depends on accurate injection of the vessel, an adequate injectate volume and concentration of sclerosant, and compression. Historically, larger veins and very tortuous veins were not considered to be good candidates for sclerotherapy due to technical limitations. Technical improvements in sclerotherapy have included the routine use of Duplex ultrasound to target refluxing vessels, luminal compression of the vein with anesthetics, and a foam/sclerosant injectate in place of liquid sclerosant. Foam sclerosants are produced by forcibly mixing a gas (e.g., air or carbon dioxide) with a liquid sclerosant (e.g., polidocanol or sodium tetradecyl sulfate). The foam is produced at the time of treatment. Varithena™ (previously known as Varisolve, BTG Plc, London) is a proprietary microfoam sclerosant that is dispersed from a canister with a controlled density and more consistent bubble size.
 
Endovenous Mechanochemical Ablation
Endovenous mechanochemical ablation utilizes both sclerotherapy and mechanical damage to the lumen. Following ultrasound imaging, a disposable catheter with a motor drive is inserted into the distal end of the target vein and advanced to the saphenofemoral junction. As the catheter is pulled back, a wire rotates at 3,500 rpm within the lumen of the vein, abrading the lumen. At the same time, a liquid sclerosant (sodium tetradecyl sulphate) is infused near the rotating wire. It is proposed that mechanical ablation allows for better efficacy of the sclerosant, without the need for the tumescent anesthesia used in radiofrequency (RF) ablation or endovenous laser ablation (EVLT).
 
Thermal Ablation
Radiofrequency ablation is performed by means of a specially designed catheter inserted through a small incision in the distal medial thigh to within 1–2 cm of the saphenofemoral junction. The catheter is slowly withdrawn, closing the vein. Laser ablation is performed similarly; a laser fiber is introduced into the greater saphenous vein under ultrasound guidance; the laser is activated and slowly removed along the course of the saphenous vein. Cryoablation uses extreme cold to cause injury to the vessel. The objective of endovenous techniques is to cause injury to the vessel, causing retraction and subsequent fibrotic occlusion of the vein. Technical developments since thermal ablation procedures were initially introduced include the use of perivenous tumescent anesthesia, which allows successful treatment of veins larger than 12 mm in diameter and helps to protect adjacent tissue from thermal damage during treatment of the lesser saphenous vein.
 
Cyanoacrylate Adhesive
Cyanoacrylate adhesive is a clear, free-flowing liquid that polymerizes in the vessel via an anionic mechanism (ie, polymerizes into a solid material on contact with body fluids or tissue). The adhesive is gradually injected along the length of the vein in conjunction with ultrasound and manual compression. The acute coaptation halts blood flow through the vein until the implanted adhesive becomes fibrotically encapsulated and establishes chronic occlusion of the treated vein. Cyanoacrylate glue has been used as a surgical adhesive and sealant for a variety of indications, including gastrointestinal bleeding, embolization of brain arteriovenous malformations, and to seal surgical incisions or other skin wounds.
 
Transilluminated Powered Phlebectomy
Transilluminated powered phlebectomy (TIPP) is an alternative to stab avulsion or hook phlebectomy. This procedure uses 2 instruments: an illuminator, which also provides irrigation, and a resector, which has an oscillating tip and can perform suction. Following removal of the saphenous vein, the illuminator is introduced via a small incision in the skin and tumescence solution (anesthetic and epinephrine) is infiltrated along the course of the varicosity. The resector is then inserted under the skin from the opposite direction, and the oscillating tip is placed directly beneath the illuminated veins to fragment and loosen the veins from the supporting tissue. Irrigation from the illuminator is used to clear the vein fragments and blood through aspiration and additional drainage holes. The illuminator and resector tips may then be repositioned, thereby reducing the number of incisions needed when compared with stab avulsion or hook phlebectomy. It has been proposed that TIPP might result in decreased operative time, decreased complications such as bruising, and faster recovery compared to the established procedures.
 
Treatment of Perforator Veins
 
Perforator veins cross through the fascia and connect the deep and superficial venous systems. Incompetent perforating veins were originally addressed with an open surgical procedure, called the Linton procedure, which involved a long medial calf incision to expose all posterior, medial, and paramedial perforators. While this procedure was associated with healing of ulcers, it was largely abandoned due to a high incidence of wound complications. The Linton procedure was subsequently modified by using a series of perpendicular skin flaps instead of a longitudinal skin flap to provide access to incompetent perforator veins in the lower part of the leg. The modified Linton procedure may be occasionally utilized for the closure of incompetent perforator veins that cannot be reached by less invasive procedures. Subfascial endoscopic perforator surgery (SEPS) is a less-invasive surgical procedure for treatment of incompetent perforators and has been reported since the mid-1980s. Guided by Duplex ultrasound scanning, small incisions are made in the skin, and the perforating veins are clipped or divided by endoscopic scissors. The operation can be performed as an outpatient procedure. Endovenous ablation of incompetent perforator veins with sclerotherapy and RF has also been reported.
 
Other
 
Deep vein valve replacement is being investigated.
 
Outcomes of interest for venous interventions include healing and recurrence, recannulation of the vein, and neovascularization. Recannulation (recanalization) is the restoration of the lumen of a vein after it has been occluded; this occurs more frequently following treatment with endovenous techniques. Neovascularization is the proliferation of new blood vessels in tissue and occurs more frequently following vein stripping. Direct comparisons of durability for endovenous and surgical procedures are complicated by these different mechanisms of recurrence. Relevant safety outcomes include the incidence of paresthesia, thermal skin injury, thrombus formation, thrombophlebitis, wound infection, and transient neurologic effects.
 
Coding
There is no specific CPT code for transilluminated powered phlebectomy. Providers might elect to use CPT codes describing stab phlebectomy (37765 or 37766) or unlisted vascular surgery procedure (37799).
 
Mechanochemical ablation should be reported with the unlisted vascular surgery procedure code 37799.
 
There is no specific CPT for microfoam sclerotherapy. Providers might elect to use CPT codes describing sclerotherapy (36468-36471) or the unlisted vascular surgery procedure code 37799. Use of codes 36475-36476 would be inappropriate as the procedure is not ablation therapy.
 
Policy/
Coverage:
Effective February 22, 2016
 
GREATER OR LESSOR SAPHENOUS VEINS
 
Treatment of the greater or lesser saphenous veins by surgery (ligation and stripping), endovenous radiofrequency or laser ablation, or microfoam sclerotherapy may be considered medically necessary for symptomatic varicose veins/venous insufficiency when the following criteria have been met:
 
    1. There is demonstrated saphenous reflux as shown by duplex demonstrating > 500 msec of reverse flow and CEAP [Clinical, Etiology, Anatomy, Pathophysiology] class C2 or greater; AND   
2. There is documentation of one or more of the following indications:
        • Ulceration secondary to venous stasis; OR
        • Recurrent superficial thrombophlebitis OR
        • Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity; OR
        • Persistent pain, swelling, itching, burning, or other symptoms are associated with saphenous reflux, AND the symptoms significantly interfere with activities of daily living, AND conservative management including compression therapy for at least 3 months has not improved the symptoms.
 
 
Treatment of greater or lesser saphenous veins by surgery, endovenous radiofrequency or laser ablation, or microfoam sclerotherapy that do not meet the criteria described above is considered cosmetic and not medically necessary.
 
 
ACCESSORY SAPHENOUS VEINS
 
Treatment of accessory saphenous veins by surgery (ligation and stripping), endovenous radiofrequency or laser ablation, or microfoam sclerotherapy may be considered medically necessary for symptomatic varicose veins/venous insufficiency when the following criteria have been met:  
    1. Incompetence of the accessory saphenous vein is isolated, OR the great or small saphenous veins had been previously eliminated (at least 3 months); AND   
2. There is demonstrated accessory saphenous reflux as shown by duplex demonstrating > 500 msec of reverse flow; AND   
3. There is documentation of one or more of the following indications:
        • Ulceration secondary to venous stasis; OR
        • Recurrent superficial thrombophlebitis; OR
        • Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity; OR
        • Persistent pain, swelling, itching, burning, or other symptoms are associated with saphenous reflux, AND the symptoms significantly interfere with activities of daily living, AND conservative management including compression therapy for at least 3 months has not improved the symptoms.
 
 
Treatment of accessory saphenous veins by surgery or endovenous radiofrequency or laser ablation, microfoam sclerotherapy, that do not meet the criteria described above is considered cosmetic and not medically necessary.
 
 
SYMPTOMATIC VARICOSE TRIBUTARIES
 
The following treatments are considered medically necessary as a component of the treatment of symptomatic varicose tributaries when performed either at the same time or following prior medically necessary treatment (surgical, radiofrequency or laser) of the saphenous veins (none of these techniques has been shown to be superior to another):  
    • Stab avulsion
    • Hook phlebectomy
    • Sclerotherapy
    • Transilluminated powered phlebectomy
 
 
Treatment of symptomatic varicose tributaries when performed either at the same time or following prior treatment of saphenous veins using any other techniques than noted above is considered investigational.
 
 
PERFORATOR VEINS
 
Surgical ligation (including subfascial endoscopic perforator surgery) or endovenous radiofrequency or laser ablation of incompetent perforator veins may be considered medically necessary as a treatment of leg ulcers associated with chronic venous insufficiency when the following conditions have been met:  
    1. There is demonstrated perforator reflux; AND
    2. The superficial saphenous veins (great, small, or accessory saphenous and symptomatic varicose tributaries) have been previously eliminated; AND
    3. Ulcers have not resolved following combined superficial vein treatment and compression therapy for at least 3 months; AND
    4. The venous insufficiency is not secondary to deep venous thromboembolism.
 
 
Ligation or ablation of incompetent perforator veins performed concurrently with superficial venous surgery is not medically necessary.
 
 
TELANGIECTASIA
 
Treatment of telangiectasia such as spider veins, angiomata, and hemangiomata is considered cosmetic and not medically necessary.
 
 
OTHER
 
Techniques for conditions not specifically listed above are investigational, including, but not limited to:  
    • Sclerotherapy techniques, other than microfoam sclerotherapy, of great, small, or accessory saphenous veins
    • Sclerotherapy of perforator veins
    • Sclerotherapy of isolated tributary veins without prior or concurrent treatment of saphenous veins
    • Stab avulsion, hook phlebectomy, or transilluminated powered phlebectomy of perforator, great or small saphenous, or accessory saphenous veins
    • Endovenous radiofrequency or laser ablation of tributary veins
    • Endovenous cryoablation of any vein
    • Mechanochemical ablation of any vein
    • Cyanoacrylate adhesive of any vein
 
 
Investigational and not medically necessary services are Plan exclusions.
 
 
 
Policy Guidelines:
The standard classification of venous disease is the CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) classification system. The following is the Clinical portion of the CEAP (Lurie et al, 2020)
 
Clinical Classification
C0 No visible or palpable signs of venous disease
C1 Telangiectasies or reticular veins
C2 Varicose veins
C2r Recurrent varicose veins
C3 Edema
C4 Changes in skin and subcutaneous tissue secondary to Chronic Venous Disease.
C4a Pigmentation and eczema
C4b Lipodermatosclerosis and atrophie blanche
C4c Corona phlebectatica
C5 Healed venous ulcer
C6 Active venous ulcer
S Symptomatic (Symptoms including ache, pain, tightness, skin irritation, heaviness, muscle cramps, as well as other complaints attributable to venous dysfunction)
A Asymptomatic
 
It should be noted that the bulk of the literature discussing the role of ultrasound guidance refers to sclerotherapy of the saphenous vein, as opposed to the varicose tributaries. When ultrasound guidance is used to guide sclerotherapy of the varicose tributaries, it would be considered either not medically necessary or incidental to the injection procedure.
 
An accessory saphenous vein, defined as an anterior vein which communicates to the saphenofemoral junction, may be ablated at the time of ablation of the ipsilateral greater saphenous vein.
 
An anterior vein which is a tributary of the greater saphenous vein and which does not communicate to the saphenofemoral junction is not considered an anterior accessory saphenous vein and treatment of this type of vein should be addressed under treatment of symptomatic varicose tributaries.
 
Rationale:
This policy has been updated periodically using the MEDLINE database. The most recent update was performed through March 13, 2025. Following is a summary of key studies to date.
 
SUMMARY OF EVIDENCE
Saphenous Veins
For individuals who have varicose veins/venous insufficiency and saphenous vein reflux who receive
endovenous thermal ablation (radiofrequency or laser), the evidence includes randomized controlled trials
(RCTs) and systematic reviews of controlled trials. The relevant outcomes are symptoms, change in disease status, morbid events, quality of life (QOL), and treatment-related morbidity (TRM). There are a number of large RCTs and systematic reviews of RCTs assessing endovenous thermal ablation of the saphenous veins. Comparison with the standard of ligation and stripping at 2- to 5-year follow-up has supported the use of both endovenous laser ablation and radiofrequency ablation (RFA). Evidence has suggested that ligation and stripping lead to more neovascularization, while thermal ablation leads to more recanalization, resulting in similar clinical outcomes for endovenous thermal ablation and surgery. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
 
For individuals who have varicose veins/venous insufficiency and saphenous vein reflux who receive MOCA, the evidence includes RCTs with 6 mo to 2 yr results that compared MOCA to thermal ablation, a prospective cohorts with follow-up out to 8 years, and retrospective case series. Relevant outcomes are symptoms, change in disease status, morbid events, quality of life, and TRM. MOCA is a combination of liquid sclerotherapy with mechanical abrasion. A potential advantage of this procedure compared with
thermal ablation is that MOCA does not require tumescent anesthesia and may result in less pain during the procedure. Results to date have been mixed regarding a reduction in intraprocedural pain compared to thermal ablation procedures. Occlusion rates at 6 mos to 2 year from RCTs indicate lower anatomic success rates compared to thermal ablation, but a difference in clinical outcomes at these early time points has not been observed. Experience with other endoluminal ablation procedures suggests that lower anatomic success in the short term is associated with recanalization and clinical recurrence between 2 to 5 years. The possibility of later clinical recurrence is supported by a prospective cohort studies with 8-year follow-up following treatment with MOCA. However, there have been improvements in technique since the cohort study was begun, and clinical progression is frequently observed with venous
disease. Because of these limitations of the single arm studies, longer follow-up in the more recently conducted RCTs is needed to establish the efficacy and durability of this procedure compared with the criterion standard of thermal ablation. The evidence is insufficient to determine the effects of the technology on health outcomes.
 
For individuals who have varicose veins/venous insufficiency and saphenous vein reflux who receive MOCA, the evidence includes RCTs and prospective cohort series. The relevant outcomes are symptoms, change in disease status, morbid events, QOL, and TRM. MOCA is a combination of liquid sclerotherapy with mechanical abrasion. Potential advantages of this procedure compared with thermal ablation are that MOCA does not require multiple needle sticks with tumescent anesthesia and may result in less pain during the procedure. The evidence on MOCA includes an RCT that compared MOCA to thermal ablation with 1 year results, an RCT with short-term results that compared mechanochemical ablation with RFA, and case series with follow-up out to three years. The short-term results of one RCT suggested that intraprocedural pain is slightly lower with MOCA than with RFA. However, the second RCT showed lower occlusion rates than thermal ablation. MOCA has been assessed in relatively few patients and for short durations. Longer follow-up in RCTs with a larger number of patients is needed to evaluate the efficacy and durability of this procedure compared with established procedures. The evidence is insufficient to determine the effects of the technology on health outcomes.
 
For individuals who have varicose veins/venous insufficiency and saphenous vein reflux who receive CAC, the evidence includes two RCTs and a prospective cohort. The relevant outcomes are symptoms, change in disease status, morbid events, QOL, and TRM. Evidence includes a multicenter noninferiority trial with follow-up through 36 months, an RCT with follow-up through 24 months, and a prospective cohort with 30 month follow up. The short-term efficacy of VenaSeal CAC has been shown to be noninferior to RFA at up to 36 months. At 24 and 36 months the study had greater than 20% loss to follow-up, but loss to follow-up was similar in the two groups at the long-term follow-up and is not expected to influence the comparative results. A second RCT (n=525) with the same active CAC ingredient (N-butyl cyanoacrylate) that is currently available outside of the US found no significant differences in vein closure between CAC and thermal ablation controls at 24 month follow-up. The CAC procedure and return to work were shorter and pain scores were lower compared to thermal ablation, although the subjective pain scores may have been influenced by differing expectations in this study. Prospective cohort studies report high closure rates at follow up to 30 months. Overall, results indicate that outcomes from CAC are at least as good as thermal ablation techniques, the current standard of care. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
 
For individuals who have varicose veins/venous insufficiency and saphenous vein reflux who receive
cryoablation, the evidence includes RCTs and multicenter series. The relevant outcomes are symptoms, change in disease status, morbid events, QOL, and TRM. Results from a recent RCT of cryoablation have indicated that this therapy is inferior to conventional stripping. Studies showing a benefit on health outcomes are needed. The evidence is insufficient to determine the effects of the technology on health outcomes.
 
Varicose Tributary Veins
For individuals who have varicose tributary veins who receive ablation (stab avulsion, sclerotherapy, or phlebectomy) of tributary veins, the evidence includes RCTs and systematic reviews of RCTs. The relevant outcomes are symptoms, change in disease status, morbid events, QOL, and TRM. The literature has shown that sclerotherapy is effective for treating tributary veins following occlusion of the saphenofemoral or saphenopopliteal junction and saphenous veins. No studies have been identified comparing RFA or laser ablation of tributary veins with standard procedures (microphlebectomy and/or sclerotherapy). Transilluminated powered phlebectomy is effective at removing varicosities; outcomes are comparable to available alternatives such as stab avulsion and hook phlebectomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
 
Perforator Veins
For individuals who have perforator vein reflux who receive ablation (eg, subfascial endoscopic perforator surgery) of perforator veins, the evidence includes RCTs and systematic reviews of RCTs. The relevant outcomes are symptoms, change in disease status, morbid events, QOL, and TRM. The literature has indicated that the routine ligation or ablation of incompetent perforator veins is not necessary for the treatment of varicose veins/venous insufficiency at the time of superficial vein procedures. However, when combined superficial vein procedures and compression therapy have failed to improve symptoms (ie, ulcers), treatment of perforator vein reflux may be as beneficial as an alternative (eg, deep vein valve replacement). Comparative studies are needed to determine the most effective method of ligating or ablating incompetent perforator veins. Subfascial endoscopic perforator surgery has been shown to be as effective as the Linton procedure with a reduction in adverse events. Although only one case series has been identified showing an improvement in health outcomes, endovenous ablation with specialized laser or radiofrequency probes has been shown to effectively ablate incompetent perforator veins with a potential decrease in morbidity compared with surgical interventions. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
 
Ongoing and Unpublished Clinical Trials
A search of online site ClinicalTrials.gov registry identified several currently unpublished trials that might influence this policy.
 
Clinical Input Received Through Academic Medical Centers and Specialty Medical Societies
2015 Input: In response to requests, input was received from 4 physician specialty societies while this policy was under review in 2015. There was no agreement on the need to treat varicose tributaries to improve functional outcomes in the absence of saphenous vein disease. Input was also mixed on the use of mechanochemical ablation or use of cyanoacrylate adhesive.
 
PRACTICE GUIDELINES AND POSITION STATEMENTS
American Venous Forum et alIn 2020, in response to published reports of potentially inappropriate application of venous procedures, the American Venous Forum, Society for Vascular Surgery, American Vein and Lymphatic Society, and the Society of Interventional Radiology published appropriate use criteria for the treatment of chronic lower extremity venous disease (Masuda et al, 2020). Appropriate use criteria were developed using the RAND/UCLA method incorporating best available evidence and expert opinion. Appropriate use criteria were determined for various scenarios (eg, symptomatic, asymptomatic, CEAP [Clinical, Etiology, Anatomy and Pathophysiology] class, axial reflux, saphenofemoral junction reflux) for the following:
    • Saphenous vein ablation
        • Great saphenous vein
        • Small saphenous vein
        • Accessory great saphenous vein
    • Non-truncal varicose veins
    • Diseased tributaries associated with saphenous ablation
    • Perforator Veins
    • Iliac Vein or inferior vena cava stenting as a first line treatment
    • Duplex ultrasound
    • Timing and Reimbursement.
Treatment of saphenous veins for asymptomatic CEAP class 1 and 2, or symptomatic class 1, was considered to be rarely appropriate or never appropriate, and treatment of symptomatic CEAP class 2,3, and 4-6 without reflux was rated as never appropriate. Based on the 2011 Guidelines from the Society for Vascular Surgery and American Venous Forum (see below), treatment of perforator veins for asymptomatic or symptomatic CEAP class 1 and 2was considered to be rarely appropriate or never appropriate. Perforator vein treatment was rated as appropriate for CEAP classes 4-6, and may be appropriate for CEAP class 3. Except for a recommendation to use endovenous procedures for perforator vein ablation, techniques used to treat veins in these scenarios were not evaluated.
 
Society for Vascular Surgery and American Venous ForumThe Society for Vascular Surgery and the American Venous Forum published clinical practice guidelines in 2011 (Gloviczki, 2011). The recommendations are rated as strong=1 or weak=2, based on a level of evidence that is either high quality=A, moderate quality=B, or low quality=C, and include the following:
 
Compression therapy for venous ulcerations and varicose veins: Compression therapy is recommended as the primary treatment to aid healing of venous ulceration (GRADE 1B, strong recommendation, moderate quality evidence). To decrease the recurrence of venous ulcers, they recommend ablation of the incompetent superficial veins in addition to compression therapy (GRADE 1A, strong recommendation, high-quality evidence). They recommend use of compression therapy for patients with symptomatic varicose veins (GRADE 2C, weak recommendation, low-quality evidence) but recommend against compression therapy as the primary treatment if the patient is a candidate for saphenous vein ablation (GRADE 1B, strong recommendation, moderate quality evidence).
 
Treatment of the incompetent great saphenous vein: Endovenous thermal ablation (radiofrequency or laser) is recommended over chemical ablation with foam (GRADE 1B, strong recommendation, moderate quality evidence) or high ligation and stripping (GRADE 1B, strong recommendation, moderate quality evidence) due to reduced convalescence and less pain and morbidity.  Cryostripping is a technique that is new in the United States, and it has not been fully evaluated.
 
Varicose tributaries: Phlebectomy or sclerotherapy are recommended to treat varicose tributaries (GRADE 1B, strong recommendation, moderate quality evidence). Transilluminated powered phlebectomy using lower oscillation speeds and extended tumescence is an alternative to traditional phlebectomy (GRADE 2C, weak recommendation, low-quality evidence).
 
Perforating vein incompetence: Selective treatment of perforating vein incompetence in patients with simple varicose veins is not recommended (CEAP class C2; GRADE 1B, strong recommendation, moderate quality evidence), but there is a GRADE 2B recommendation (weak recommendation, moderate quality evidence) for treatment of pathologic perforating veins (outward flow of >500 ms duration, with a diameter of >3.5 mm) located underneath healed or active ulcers (CEAP class C5-C6) by subfascial endoscopic perforating vein surgery, sclerotherapy, or thermal ablations (GRADE 1C, weak recommendation, low-quality evidence).
 
The Society for Vascular Surgery, the American Vein and Lymphatic Society (AVLS), and the American Venous Forum published a joint clinical practice guideline in 2022 on management of lower extremity varicose veins (Gloviczki, 2023). The guideline will be published in sections; the first part (published in 2022) focuses on duplex scanning and treatment of superficial truncal reflex. Superficial truncal veins are defined as the great saphenous vein, small saphenous vein, anterior accessory great saphenous vein, and posterior accessory great saphenous vein. A summary of the guideline recommendations is provided below. The second part of the guideline was published in 2023 and focuses on the management of varicose vein patients with compression, treatment with drugs and nutritional supplements, evaluation and treatment of varicose tributaries, superficial venous aneurysms, and management of complications of varicose veins and their treatment (Gloviczki, 2024).
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Summary of Recommended Treatment of Superficial Truncal Reflex:
    • Symptomatic varicose veins and axial reflux
        • Reflux in the great or small saphenous vein - superficial venous intervention preferred over long-term compression stockings (Grade 1B; Strength of Recommendation – Strong; Quality of Evidence – Moderate)
        • Reflux in the anterior accessory or posterior accessory great saphenous vein - superficial venous intervention preferred over long-term compression stockings (Grade 2C; Strength of Recommendation - Weak; Quality of Evidence - Low)
        • Reflux in the superficial truncal vein - compression therapy suggested for primary treatment (Grade 2C; Strength of Recommendation - Weak; Quality of Evidence - Low)
        • Reflux in the great saphenous vein - endovenous ablation preferred over high ligation and stripping (Ligation and stripping can be performed if endovenous ablation is not feasible) (Grade 1B; Strength of Recommendation - Strong; Quality of Evidence - Moderate)
        • Reflux in the small saphenous vein - endovenous ablation preferred over high ligation and stripping (Ligation and stripping can be performed if endovenous ablation is not feasible.) (Grade 1C; Strength of Recommendation - Strong; Quality of Evidence - Low)
        • Reflux in the anterior accessory or posterior accessory great saphenous vein - endovenous ablation (with phlebectomy if needed) over ligation and stripping (Ligation and stripping can be performed if endovenous ablation is not feasible.) (Grade 2C; Strength of Recommendation - Weak; Quality of Evidence - Low)
        • Patients who place a high priority on long-term outcomes (quality of life and recurrence) - laser ablation, radiofrequency ablation, or ligation and stripping over ultrasound-guided foam sclerotherapy (Grade 2C or 2B; Strength of Recommendation - Weak; Quality of Evidence - Moderate or Low)
    • Symptomatic axial reflux
        • Reflux in the great saphenous vein - thermal and nonthermal ablation recommended (Grade 1B; Strength of Recommendation - Strong; Quality of Evidence - Moderate)
        • Reflux in the small saphenous vein - thermal and nonthermal ablation recommended (Grade 1C; Strength of Recommendation - Strong; Quality of Evidence - Low)
        • Reflux in the anterior accessory or posterior accessory great saphenous vein - either thermal or nonthermal ablation suggested (Grade 2C; Strength of Recommendation - Weak; Quality of Evidence - Low)
    • Varicose veins (CEAP class C2)
        • Reflux in the great or small saphenous vein - recommend against concomitant initial ablation and treatment of incompetent perforating veins (Grade 1C; Strength of Recommendation - Strong; Quality of Evidence - Low)
        • Reflux in the anterior accessory or posterior accessory great saphenous vein - recommend against concomitant initial ablation and treatment of incompetent perforating veins (Grade 2C; Strength of Recommendation - Weak; Quality of Evidence - Low)
        • Persistent or recurrent symptoms after previous complete ablation - treatment of perforating vein incompetence suggested (Grade 2C; Strength of Recommendation - Weak; Quality of Evidence - Low)
    • Symptomatic reflux and associated varicosities
        • Reflux in the great or small saphenous vein - ablation and concomitant phlebectomy or ultrasound-guided foam sclerotherapy recommended (Grade 1C; Strength of Recommendation - Strong; Quality of Evidence - Low)
        • Reflux in the anterior accessory or posterior accessory great saphenous vein - ablation and concomitant phlebectomy or ultrasound-guided foam sclerotherapy suggested (Grade 2C; Strength of Recommendation - Weak; Quality of Evidence – Low)
American Vein and Lymphatic Society
In 2015, the American Vein and Lymphatic Society (AVL, previously named the American College of Phlebology) published guidelines on the treatment of superficial vein disease. AVL gave a Grade 1 recommendation based on high quality evidence that compression is an effective method for the management of symptoms, but when patients have a correctable source of reflux definitive treatment should be offered unless contraindicated. AVL recommends against a requirement for compression therapy when a definitive treatment is available. AVL gave a strong recommendation based on moderate quality evidence that endovenous thermal ablation is the preferred treatment for saphenous and accessory saphenous vein incompetence, and gave a weak recommendation based on moderate quality evidence that mechanochemical ablation may also be used to treat venous reflux.
 
In 2017, AVL published guidelines on the treatment of refluxing accessory saphenous veins (Gibson et al, 2017). The College gave a Grade 1 recommendation based on level C evidence that patients with symptomatic incompetence of the accessory saphenous veins be treated with endovenous thermal ablation or sclerotherapy to reduce symptomatology. The guidelines noted that although accessory
saphenous veins may drain into the great saphenous vein before it drains into the common femoral vein, they can also empty directly into the common femoral vein.
 
In 2025, AVLS published a position statement on mechanochemical chemically assisted ablation of varicose veins for venous insufficiency (Blebea et al, 2025). The following conclusion and recommendations were made: "Mechanical occlusion chemically assisted venous ablation is effective in alleviating symptoms and a safe treatment option for venous insufficiency. As a non-thermal ablation method, MOCA [mechanical occlusion chemically assisted ablation] obviates the need for tumescent anesthesia and thus results in less procedural discomfort and risk of thermal nerve or skin injury. It may be used in both the below knee distal GSV [great saphenous veins] as well as the SSV [small saphenous veins] with no risk of thermal injury to the adjacent nerves. However, it is associated with significantly lower rates of vessel closure and higher recanalization rates when followed for more than 1 year compared to both radiofrequency ablation and endovenous laser ablation." "It is an available option for those in whom thermal ablation is not suitable."
 
National Institute for Health and Care Excellence
NICE issued updated guidance on ultrasound-guided foam sclerotherapy for varicose veins in 2013.  The guidance states that:
 
“1.1 Current evidence on the efficacy of ultrasound-guided foam sclerotherapy for varicose veins is adequate. The evidence on safety is adequate, and provided that patients are warned of the small but significant risks of foam embolization (see section 1.2), this procedure may be used with normal arrangements for clinical governance, consent and audit.
 
1.2 During the consent process, clinicians should inform patients that there are reports of temporary chest tightness, dry cough, headaches and visual disturbance, and rare but significant complications including myocardial infarction, seizures, transient ischemic attacks and stroke.”
 
In 2015, NICE published a technology assessment on the clinical effectiveness and cost-effectiveness of foam sclerotherapy, endovenous laser ablation, and surgery for varicose veins.
 
In 2016, NICE revised its guidance on endovenous mechanochemical ablation, concluding that "Current evidence on the safety and efficacy of endovenous mechanochemical ablation for varicose veins appears adequate to support the use of this procedure...."
 
U.S. Preventive Services Task Force Recommendations
Not applicable.
 
Regulatory Status
In 2015, the VenaSeal® Closure System (Sapheon, a part of Medtronic) was approved by the U.S. Food and Drug Administration (FDA) through the premarket approval process for the permanent closure of clinically significant venous reflux through endovascular embolization with coaptation. The VenaSeal Closure System seals the vein using a cyanoacrylate adhesive agent. FDA product code: PJQ.
 
Varithena™ (formerly known as Varisolve®, BTG Plc, London) is a sclerosant microfoam made with a proprietary gas mix. It was approved by FDA in 2013 under a new drug application for the treatment of incompetent great saphenous veins, accessory saphenous veins and visible varicosities of the great saphenous vein system above and below the knee.
 
The following devices have received specific U.S. Food and Drug Administration (FDA) marketing clearance for the endovenous treatment of superficial vein reflux:  
    • In 1999, the VNUS® Closure™ System, a radiofrequency device, was cleared by the FDA through the 510(k) process for “endovascular coagulation of blood vessels in patients with superficial vein reflux.” In 2005, the VNUS RFS™ and RFSFlex™ devices were cleared by the FDA for “use in vessel and tissue coagulation including treatment of incompetent (ie, refluxing) perforator and tributary veins.” In 2008, the modified VNUS® ClosureFast™ Intravascular Catheter was cleared by the FDA through the 510(k) process. FDA product code: GEI.
    • In 2002, the Diomed 810 nm surgical laser and EVLT™ (endovenous laser therapy) procedure kit were cleared by the FDA through the 510(k) process “…for use in the endovascular coagulation of the great saphenous vein of the thigh in patients with superficial vein reflux.” FDA product code: GEX.
    • In 2005, a modified Erbe Erbokryo® cryosurgical unit (Erbe USA) was approved by the FDA for marketing. A variety of clinical indications are listed, including cryostripping of varicose veins of the lower limbs. FDA product code: GEH.
    • In 2003, the Trivex® system (InaVein), a device for transilluminated powered phlebectomy, was cleared by FDA through the 510(k) process for “ambulatory phlebectomy procedures for the resection and ablation of varicose veins.” FDA product code: DNQ.
    • In 2008, the ClariVein® Infusion Catheter (Vascular Insights) was cleared by the FDA through the 510(k) process (K071468) for mechanochemical ablation. FDA determined that this device was substantially equivalent to the Trellis® Infusion System (K013635) and the Slip-Cath® Infusion Catheter (K882796). The system includes an infusion catheter, motor drive, stopcock, and syringe, and is intended for the infusion of physician-specified agents in the peripheral vasculature.
FDA product code: KRA
 
 
Current References
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CPT/HCPCS:
36465Injection 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)
36466Injection 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
36468Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk
36470Injection of sclerosant; single incompetent vein (other than telangiectasia)
36471Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg
36473Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated
36474Endovenous 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)
36475Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated
36476Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)
36478Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated
36479Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)
36482Endovenous 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
36483Endovenous 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)
37500Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS)
37700Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions
37718Ligation, division, and stripping, short saphenous vein
37722Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below
37735Ligation 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
37760Ligation of perforator veins, subfascial, radical (Linton type), including skin graft, when performed, open,1 leg
37761Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg
37765Stab phlebectomy of varicose veins, 1 extremity; 10 20 stab incisions
37766Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions
37780Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure)
37785Ligation, division, and/or excision of varicose vein cluster(s), 1 leg
37799Unlisted procedure, vascular surgery
S2202Echosclerotherapy
ICD9:
ICD10:
I83.001Varicose veins of unsp lower extremity with ulcer of thigh
I83.002Varicose veins of unsp lower extremity with ulcer of calf
I83.003Varicose veins of unsp lower extremity with ulcer of ankle
I83.004Varicos vn unsp lower extremity w ulcer of heel and midfoot
I83.005Varicos vn unsp lower extremity w ulcer oth part of foot
I83.008Varicos vn unsp low extrm w ulcer oth part of lower leg
I83.009Varicose veins of unsp lower extremity w ulcer of unsp site
I83.011Varicose veins of right lower extremity with ulcer of thigh
I83.012Varicose veins of right lower extremity with ulcer of calf
I83.013Varicose veins of right lower extremity with ulcer of ankle
I83.014Varicose veins of r low extrem w ulcer of heel and midfoot
I83.015Varicose veins of r low extrem w ulcer oth part of foot
I83.018Varicose veins of r low extrem w ulcer oth part of lower leg
I83.019Varicose veins of right lower extremity w ulcer of unsp site
I83.021Varicose veins of left lower extremity with ulcer of thigh
I83.022Varicose veins of left lower extremity with ulcer of calf
I83.023Varicose veins of left lower extremity with ulcer of ankle
I83.024Varicose veins of l low extrem w ulcer of heel and midfoot
I83.025Varicose veins of l low extrem w ulcer oth part of foot
I83.028Varicose veins of l low extrem w ulcer oth part of lower leg
I83.029Varicose veins of left lower extremity w ulcer of unsp site
I83.10Varicose veins of unsp lower extremity with inflammation
I83.11Varicose veins of right lower extremity with inflammation
I83.12Varicose veins of left lower extremity with inflammation
I83.201Varicos vn unsp low extrm w ulc of thigh and inflammation
I83.202Varicos vn unsp low extrm w ulc of calf and inflammation
I83.203Varicos vn unsp low extrm w ulc of ankle and inflammation
I83.204Varicos vn unsp low extrm w ulc of heel and midft and inflam
I83.205Varicos vn unsp low extrm w ulc oth part of foot and inflam
I83.208Varicos vn unsp low extrm w ulc oth prt low extrm and inflam
I83.209Varicos vn unsp low extrm w ulc of unsp site and inflam
I83.211Varicos vn of r low extrem w ulc of thigh and inflammation
I83.212Varicos vn of r low extrem w ulc of calf and inflammation
I83.213Varicos vn of r low extrem w ulc of ankle and inflammation
I83.214Varicos vn of r low extrem w ulc of heel & midft and inflam
I83.215Varicos vn of r low extrem w ulc oth part of foot and inflam
I83.218Varicos vn of r low extrem w ulc oth prt low extrm & inflam
I83.219Varicos vn of r low extrem w ulc of unsp site and inflam
I83.221Varicos vn of l low extrem w ulc of thigh and inflammation
I83.222Varicos vn of l low extrem w ulc of calf and inflammation
I83.223Varicos vn of l low extrem w ulc of ankle and inflammation
I83.224Varicos vn of l low extrem w ulc of heel & midft and inflam
I83.225Varicos vn of l low extrem w ulc oth part of foot and inflam
I83.228Varicos vn of l low extrem w ulc oth prt low extrm & inflam
I83.229Varicos vn of l low extrem w ulc of unsp site and inflam
I83.811Varicose veins of right lower extremity with pain
I83.812Varicose veins of left lower extremity with pain
I83.813Varicose veins of bilateral lower extremities with pain
I83.819Varicose veins of unspecified lower extremity with pain
I83.891Varicose veins of r low extrem with other complications
I83.892Varicose veins of l low extrem with other complications
I83.893Varicose veins of bi low extrem w oth complications
I83.899Varicos vn unsp lower extremity with other complications
I87.2Venous insufficiency (chronic) (peripheral)
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