REVIEW REQUEST FOR
Treatment of Varicose Veins (Lower Extremities)
Provider Data Collection Tool Based on Medical Policy SURG.00037
Policy Last Review Date: 11/13/2014
Policy Effective Date:
01/13/2015
Provider Tool Effective Date:
Individual Name:
Date of Birth:
Insurance Identification Number:
Individual Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
01/13/2015
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:
Service Requested (CPT if known):
Diagnosis Code(s) (if known):
Place of Service:
Outpatient
Home
Inpatient
Other:
Procedure will be done on (if applicable):
Left
Right
Bilateral
Please check all that apply:
Request is for endoluminal radiofrequency ablation or endoluminal laser ablation (check all that apply)
Of the greater saphenous vein (GSV) or lesser saphenous veins (LSV)
For perforator vein ablation as an alternative to perforator vein ligation
For treatment of saphenous vein tributaries or extensions (e.g. anterolateral thigh, anterior accessory saphenous
and Giacomini veins)
Of symptomatic varicose tributaries as an alternative to adjunctive sclerotherapy or echosclerotherapy
Other treatment (please list):
Request is for sclerotherapy or echosclerotherapy including ultrasound guided foam sclerotharapy (UGFS),
Of varicose tributary or extension [for example, anterolateral thigh vein, anterior accessory saphenous vein, or
Giacomini 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 procedure or endoluminal laser ablation procedure
Of varicose tributary or extension [e.g. anterolateral thigh vein, anterior accessory saphenous vein, or Giacomini
vein(s)] or perforator veins for residual or recurrent symptoms and surgical ligation and stripping, endoluminal
radiofrequency ablation, or endoluminal laser ablation of the greater or lesser saphenous veins was previously
performed
As the sole* treatment of symptomatic varicose tributary or extension or perforator veins in the presence of
valvular incompetence of the greater or lesser saphenous veins (by Doppler or duplex ultrasound scanning)
As the sole*treatment of symptomatic varicose tributary or perforator veins in the absence of saphenous vein
reflux or major saphenous vein tributary reflux
To treat secondary varicose veins resulting from deep-vein thrombosis or arteriovenous fistulae when used to treat
valvular incompetence (ithat is,. reflux) of the greater or lesser saphenous veins with or without associated
ligation of the saphenofemoral junction
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 greater or lesser saphenous veins
Other treatment (please list):
* 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 greater or lesser saphenous veins
Request is for endoluminal cryoablation
Request is for mechanochemical ablation of any vein
Request is for COMPASS (Comprehensive Objective Mapping, Precise Image-guided Injection, Antireflux Positioning and
Sequential Sclerotherapy) protocol
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™)
Medical records document (check all that apply):
Junctional (saphenofemoral for GSV; saphenopopliteal for LSV) incompetence (that is reflux with retrograde flow
greater than 0.5 second duration) based on vein anatomy is documented 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) which:
Are interfering with activities of daily living
Persist despite appropriate non-surgical management for no less than 6 weeks, such as leg elevation, exercise and
medication prior to the required treatment
Persist despite a trial of properly fitted gradient compression stockings for at least 6 weeks
Ulceration secondary to stasis dermatitis
Hemorrhage from a superficial varicosity
Other treatment (please list):
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
Form and Attestation (Please Print)*
Date
*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.
Page 2 of 2