Review request for



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REVIEW REQUEST FOR

Treatment of Varicose Veins (Lower Extremities)

Provider Data Collection Tool Based on Medical Policy SURG.00037

Policy Last Review Date: 03/22/2018

Publish Date: 04/25/2018

Provider Tool Effective Date: 04/25/2018






Individual Name:      

Date of Birth:     

Insurance Identification Number:     

Individual Phone Number:      

Ordering Provider Name & Specialty:     

Provider ID Number:      

Office Address:      

Office Phone Number:     

Office Fax Number:      

Rendering Provider Name & Specialty:     

Provider ID Number:      

Office Address:      

Office Phone Number:     

Office Fax Number:      

Facility Name:     

Facility ID Number:      

Facility Address:      

Date/Date Range of Service:     

Place of Service: Home Inpatient

Outpatient Other:                

Service Requested (CPT if known):     

Diagnosis Code(s) (if known):      


Procedure will be done on (if applicable):

Left Right Bilateral

This medical policy based data collection tool is for a medical necessity review request for various modalities (listed below) for the treatment of valvular incompetence (reflux) of the great saphenous vein (GSV) or small saphenous vein (SSV) (also known as greater saphenous vein or lesser saphenous vein, respectively) and associated varicose tributaries as well as telangiectatic dermal veins.


The following modalities are included in this document:

  • Coil embolization;

  • Cyanoacrylate adhesion (VenaSealTM Closure System);

  • Echosclerotherapy (also known as ultrasound-guided sclerotherapy or ultrasound guided foam sclerotherapy [UGFS] [for example, Varithena], or microfoam sclerotherapy);

  • Endoluminal cryoablation;

  • Endoluminal laser ablation (also known as EVLT or ELAS);

  • Endoluminal radiofrequency ablation (also known as VNUS Closure® System or Venefit Procedure);

  • Endovenous thermal ablation (EVTA) which includes radiofrequency and laser ablation;

  • Mechanochemical ablation (for example: ClariVein®);

  • Sclerotherapy



PLEASE READ CAREFULLY AND MARK ALL THAT APPLY TO THE INDIVIDUAL:
Request is for endoluminal radiofrequency ablation or endoluminal laser ablation

(If checked, mark all that apply to the individual)

Procedure to be done on the great saphenous vein (GSV)

*If checked, please specify: Right Left Bilateral



Procedure to be done on the small saphenous veins ( SV)

*If checked, please specify: Right Left Bilate



Procedure is an alternative to perforator vein ligation

Procedure is for treatment of saphenous vein tributaries or extensions (for example, anterolateral thigh veins,

anterior accessory saphenous veins, and intersaphenous veins)



Procedure is an alternative to adjunctive sclerotherapy or echosclerotherapy of symptomatic varicose tributaries

There is junctional (saphenofemoral for GSV; saphenopopliteal for SSV) incompetence (that is, reflux with

retrograde flow of 0.5 second duration or greater) based on vein anatomy confirmed by Doppler or duplex

ultrasound scanning

Symptoms of venous insufficiency or recurrent thrombophlebitis (including but not limited to: aching, burning,

itching, cramping, or swelling during activity or after prolonged sitting)



(If checked, mark all of the following that apply to the individual)

Symptoms cause discomfort to the degree that employment or activities of daily living are compromised

Symptoms persist despite appropriate non-surgical management, for no less than 6 weeks, such as leg elevation and exercise

Symptoms persist despite a trial of properly fitted gradient compression stockings for at least 6 weeks

There is ulceration secondary to stasis dermatitis

There is hemorrhage from a superficial varicosity
Request is for sclerotherapy or echosclerotherapy including ultrasound guided foam sclerotherapy (UGFS),

Procedure to be done on varicose tributary or extension (for example, anterolateral thigh vein, anterior accessory

saphenous vein, or intersaphenous vein(s)) or perforator veins greater than 3.0 mm in diameter with demonstrated

reflux to be performed AT THE SAME TIME as an endoluminal radiofrequency ablation or endoluminal laser

ablation procedure



Procedure to be done on varicose tributary or extension (for example, anterolateral thigh vein, anterior accessory

saphenous vein, or intersaphenous vein(s)) or perforator veins greater than 3.0 mm in diameter with demonstrated

reflux for RESIDUAL OR RECURRENT SYMPTOMS and surgical ligation and stripping, endoluminal

radiofrequency ablation, or endoluminal laser ablation of the great or small saphenous veins was previously

performed

Procedure to be done as the sole* treatment of symptomatic varicose tributary or extension or perforator veins in

the presence of valvular incompetence of the great or small saphenous veins (by Doppler or duplex ultrasound

scanning)

Procedure to be done as the sole*treatment of symptomatic varicose tributary or perforator veins in the absence of

saphenous vein reflux or major saphenous vein tributary reflux



Procedure to be done to treat secondary varicose veins resulting from deep-vein thrombosis or arteriovenous

fistulae when used to treat valvular incompetence (that is, reflux) of the great or small saphenous veins with or

without associated ligation of the saphenofemoral junction

Procedure to be done as part of other protocols for sclerotherapy, including, but not limited to the COMPASS

protocol, for the treatment of valvular incompetence (that is, reflux) of the great or small saphenous veins



Procedure to be done for a reason not specified above.

Please specify:                                                                       



There is junctional (saphenofemoral for GSV; saphenopopliteal for SSV) incompetence (that is, reflux with

retrograde flow of 0.5 second duration or greater) based on vein anatomy confirmed by Doppler or duplex

ultrasound scanning

Please continue on next page
Symptoms of venous insufficiency or recurrent thrombophlebitis (including but not limited to: aching, burning,

itching, cramping, or swelling during activity or after prolonged sitting)



(If checked, mark all of the following that apply to the individual)

Symptoms cause discomfort to the degree that employment or activities of daily living are compromised

Symptoms persist despite appropriate non-surgical management, for no less than 6 weeks, such as leg elevation and exercise

Symptoms persist despite a trial of properly fitted gradient compression stockings for at least 6 weeks

There is ulceration secondary to stasis dermatitis

There is hemorrhage from a superficial varicosity
* NOTE: Sole refers to sclerotherapy without concomitant or prior ligation (with or without vein stripping), or endoluminal

radiofrequency ablation, or endoluminal laser ablation for valvular incompetence of the great or small saphenous veins


Request is for endoluminal cryoablation

Request is for mechanochemical ablation of any vein

Request is for coil embolization as treatment of lower extremity veins

Request is for COMPASS (Comprehensive Objective Mapping, Precise Image-guided Injection, Antireflux Positioning

and Sequential Sclerotherapy) protocol for the treatment of valvular incompetence (that is, reflux) of the great or small

saphenous veins.

Request is for treatment of the telangiectatic dermal veins (for example, reticular, capillary, venule), which may be

described as "spider veins" or "broken blood vessels using sclerotherapy or various laser treatments (including tunable dye

or pulsed dye laser, for example, PhotoDerm™, VeinLase™, Vasculite™)

Request is for cyanoacrylate adhesion (for example, VenaSeal Closure System) as treatment of venous reflux

Request is for other treatment not specified above.

Please specify:                                                                                 

This request is being submitted:

Pre-Claim

Post–Claim. If checked, please attach the claim or indicate the claim number                                    

I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its designees may perform a routine audit and request the medical documentation to verify the accuracy of the information reported on this form.


                                                                  

Name and Title of Provider or Provider Representative Completing Date



Form and Attestation (Please Print)*
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization management services on behalf of your health benefit plan or the administrator of your health benefit plan.


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