Seton Health Plan Coverage Guidelines for Varicose Vein Referral

Seton Health Plan

Coverage Guidelines

Varicose Vein Referral

Policy:

1) Seton Health Plan (SHP) will review Medical Assistance Program (MAP) patient referrals for varicose vein evaluations.

2) Primary care physician will submit varicose vein evaluation requests to SHP and include supporting documentation (i.e. conservative measures taken, physical findings and related test results).

3) SHP will approve an evaluation visit at Austin Radiology Associates (ARA) if the following criteria have been met:

> No significant symptomatic improvement in response to 3-month trial of fitted elastic support hose AND

> Objective complications — symptoms causing clinically significant functional impairment as indicated by 1 or more of the following: AND

• Leg pain
• Leg fatigue
• Leg edema

> Ultrasound lower extremities to RIO DVT OR

> 1 or more of the following complications or recurrent symptoms:

• Bleeding from a varicosity that has eroded skin
• Large superficial varices around skin ulcer
• Persistent or recurrent venous stasis ulcer

4) Initial evaluation authorization for ARA will include the following:

> 99241 — Consult x 2

> 93970 — Duplex Doppler

5) If ARA determines that intervention is required they will contact SHP to obtain authorization. Procedure codes for EVLT will depend on patient’s condition and may include the following codes: 36478; 37799; 37765; 37766; 36470; 36471; 36479