Description
Documentation will be reviewed to determine if claims for Endovenous Radiofrequency Ablation (ERFA) and Endovenous Laser Treatment (EVLT) for Lower Extremity Varicose Veins meet Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary.
Affected Code(s)
36475, 36476, 36478, 36479, 76937
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. Medicare Claims Processing Manual, Ch 12, §40.6 Claims for Multiple Surgeries
9. CGS Administrators, LLC, LCD L34082- Varicose Veins of the Lower Extremity, Treatment of; Effective 10/01/2015; Revised 10/5/2023
10. First Coast Service Options, Inc., LCD L38720- Treatment of Chronic Venous Insufficiency of the Lower
Extremities; Effective 12/27/2020
11. National Government Services, Inc., LCD L33575- Varicose Veins of the Lower Extremity, Treatment of; Effective 10/01/2015; Revised 11/21/2019
12. Noridian Healthcare Solutions, LLC, LCD L34209- Treatment of Varicose Veins of the Lower Extremities; Effective 10/01/2015; Revised 12/01/2019
13. Noridian Healthcare Solutions, LLC, LCD L34010- Treatment of Varicose Veins of the Lower Extremities; Effective 10/01/2015; Revised 12/01/2019
14. Novitas Solutions, Inc., LCD L34924- Treatment of Chronic Venous Insufficiency of the Lower Extremities; Effective 10/01/2015; Revised 12/27/2020
15. Palmetto GBA LCD L39121- Treatment of Varicose Veins of the Lower Extremities; Effective 4/03/2022; Revised 11/16/2023
16. Wisconsin Physicians Service Insurance Corp., LCD L34536- Treatment of Varicose Veins of the Lower Extremities; Effective 10/01/2015; Revised 8/31/2023
17. CGS Administrators, LLC, LCA A57305- Billing and Coding: Varicose Veins of the Lower Extremity, Treatment of; Effective 9/26/2019; Revised 11/16/2023
18. First Coast Service Options, Inc., LCA A58250- Billing and Coding: Treatment of Varicose Veins of the Lower Extremity; Effective 12/27/2020; Revised 3/11/2021
19. National Government Services, Inc., LCA A52870- Billing and Coding: Treatment of Varicose Veins of the Lower Extremity; Effective 10/01/2015; Revised 11/21/2019
20. Noridian Healthcare Solutions, LLC, LCA A57706- Billing and Coding: Treatment of Varicose Veins of the Lower Extremities; Effective 12/01/2019; Revised 01/01/2023
21. Noridian Healthcare Solutions, LLC, LCA A57707- Billing and Coding: Treatment of Varicose Veins of the Lower Extremities; Effective 12/01/2019; Revised 01/01/2023
22. Novitas Solutions, Inc., LCA A55229- Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities; Effective 8/11/2016; Revised 3/11/2021
23. Palmetto GBA LCA A58876- Billing and Coding: Treatment of Varicose Veins of the Lower Extremities; Effective 4/03/2022; Revised 5/02/2024
24. Wisconsin Physicians Service Insurance Corp., LCA A56914- Billing and Coding: Treatment of Varicose Veins of the Lower Extremities; Effective 8/29/2019; Revised 8/31/2023
25. AMA CPT Codebook