Coverage Criteria for Peripheral Venous Examinations

According to National Government Services LCD L33627, indications for venous examinations are separated into three major categories: deep vein thrombosis (DVT), chronic venous insufficiency, and vein mapping. Studies are medically necessary only if the patient is a candidate for anticoagulation, thrombolysis or invasive therapeutic procedure(s).

Since the signs and symptoms of arterial occlusive disease and venous disease are so divergent, the performance of simultaneous arterial and venous studies during the same encounter should be accompanied by a clear assessment of the clinical need for both studies. Consequently, documentation clearly supporting the medical necessity of both procedures performed during the same encounter must be available in the patient’s medical record. 

Deep Vein Thrombosis (DVT)

The signs and/or symptoms of DVT are relatively non-specific; and due to the risk associated with pulmonary embolism (PE), objective testing is allowed in patients who are candidates for anticoagulation or invasive therapeutic procedures for the following:

• Clinical signs and/or symptoms of DVT including, but not limited to, edema, tenderness, inflammation, and/or erythema;
• Clinical signs and/or symptoms of pulmonary embolus (PE) including, but not limited to, hemoptysis, chest pain, and/or dyspnea;
• Unexplained lower extremity edema status, post major surgical procedures, trauma, other or progressive illness/condition; and/or
• Unexplained lower extremity pain, excluding pain of skeletal origin.

These studies are rarely considered medically necessary for the following:

• Bilateral limb edema in the presence of signs and/or symptoms of congestive heart failure, exogenous obesity and/or arthritis; and/or
• Follow-up of phlebitis unless signs/symptoms suggest possible extension of thrombus.

Chronic Venous Insufficiency

Chronic venous insufficiency may be divided into three categories: primary varicose veins, recurrent DVT, and post-thrombotic (post-phlebitic) syndrome. Peripheral venous studies may be indicated for the evaluation of:

• Venous function in patients with ulceration suspected to be secondary to venous insufficiency when documenting venous valvular incompetence prior to invasive therapeutic intervention;
• Varicose veins by themselves do not indicate medical necessity, but medical necessity may be indicated when they are accompanied by significant pain or stasis dermatitis; and/or
• Superficial thrombophlebitis involving the proximal thigh (to investigate whether there was thrombus at the saphenofemoral junction that would demand either anticoagulation or surgical ligation).

Vein Mapping

Mapping the saphenous veins prior to scheduled revascularization procedures is covered by Medicare when it is expected that an autologous vein will be used to help select an optimal native vessel for grafting .

Vein mapping is not always necessary as a routine pre-operative study, and clinical indications should be noted on the request.  

Vein mapping may be performed prior to creating a dialysis fistula. Please see “VI. Vessel Mapping of Vessels for Hemodialysis Access (93970, 93971, G0365).”

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