Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers of Medicare and Medicaid Services (CMS), is conducting post-payment review of claims for Medicare Part B for chronic venous insufficiency billed on dates of service from January 1, 2023, through June 17, 2026. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

Chronic Venous Insufficiency (CVI) results from venous valve reflux (incompetence), leading to dilated, tortuous superficial veins (varicose veins) in the lower extremities. These can cause edema, skin changes, venous ulcers, pain, and reduced quality of life, while spider veins are typically treated for cosmetic purposes.

Initial management includes conservative treatments such as exercise, leg elevation, weight loss, compression therapy, and avoiding prolonged immobility. If symptoms persist, treatment options include sclerotherapy (injection of a solution into the vein), surgical ligation/stripping, or newer minimally invasive procedures like endoluminal radiofrequency ablation (RFA), which is an outpatient procedure using ultrasound guidance, catheter placement, and heat to eliminate venous reflux, while laser ablation close the veins by causing thermal damage and fibrosis.

Pre-procedural Doppler or duplex ultrasound is commonly used to assess venous anatomy, and Medicare covers one medically necessary ultrasound as well as treatments to determine the extent and configuration of the varicosities when it is medically necessary. Medicare does not provide coverage for cosmetic surgery.

Reason for Review

The SMRC is tasked to perform data analysis and conduct medical record reviews on claims billed with CPT codes billed with date of service January 1, 2023, through June 17, 2026.

The SMRC will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

Access related project details below.

• Documentation Requirements
• References

Documentation Requirements

Below is a list of documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

We note that ADRs will include specific documentation to be submitted based on the local coverage policies established by each MAC. Please refer to your individual ADR for specific documentation requirements.

The billing practitioner is responsible for obtaining the appropriate clinical documentation from the ordering or referring physician for the treatment of chronic venous insufficiency and confirm all medical necessity criteria have been met.

1. Physician/Non-Physician Practitioner (NPP) order or evidence of intent to order for the treatment of chronic venous insufficiency for the date of service under review
2. Performance and results of appropriate tests with supporting imaging and anatomy details to confirm the pathology of the vascular anatomy, and presence and location of incompetent perforating veins, and necessity of utilizing ultrasound guidance, if used for the date of service under review
3. Doppler ultrasound or duplex studies used to map the anatomy of the venous system prior to the procedure and post-procedure duplex within one week of ablation are required, when applicable
4. Documentation of presurgical conservative measures/treatment, and the failure of conservative management in keeping with local coverage policies.
5. Operative /Procedure Report from the ordering and/or referring provider that support the medical necessity of the treatment of chronic venous insufficiency, including location and number of varicosities, level of incompetence of the vein, and the veins involved, for the date of service under review
6. History and physical findings supporting the diagnosis of symptomatic varicose veins along with supporting documentation that the patient remains symptomatic prior to the procedure performed, including exclusion of other causes of edema, ulceration, and pain in the limbs
7. Documentation to support the code(s) and modifier(s) billed
8. Providers and/or suppliers are encouraged to review the documentation prior to submission, to ensure that signature information is available. Please include a signature log or signature attestation for any missing or illegible signature within the medical record
9. If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician
10. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
11. Medical record documentation to support national and local requirements
12. Any other supporting/pertinent documentation
13. If medical record documentation is submitted via esMD, beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation

References

Social Security Act (SSA) Title XVIII

• §1815(a) Payment to Providers of Services
• §1832(a)(2)(F) Scope of Benefits
• §1833(e) Payment of Benefits
• §1862 (a)(7) Exclusion of Routine Physical examinations
• §1862 (a)(10) Exclusion of Cosmetic Surgery
• §1862(a)(1)(A), (a)(10) Exclusions from Coverage and Medicare as Secondary Payer
• §1879 (a)(1) Limitation on Liability of Beneficiary Where Medicare Claims Are Disallowed

42 Code of Federal Regulations (CFR)

• §410.3 Scope of benefits
• §411.15(k)(1) Particular services excluded from coverage
• §424.5 Basic Conditions
• §416.65 Covered surgical procedures

Internet-Only Manual (IOM), Publication (Pub.) 100-03, Medicare National Coverage Determination Manual (NCD)

• Chapter (Ch.) 1, Part 4, §220.5 Ultrasound Diagnostic Procedures

IOM, Pub. 100-02, Medicare Benefit Policy Manual (MBPM)

• Ch. 15, §30.1 Provider-Based Physician Services
• Ch. 15, §260 Ambulatory Surgical Center Services
• Ch. 16, General Exclusions from Coverage
• Ch. 16, §20 Services Not Reasonable and Necessary
• Ch. 16, §120 Cosmetic Surgery

IOM, Pub.100-04, Medicare Claims Processing Manual (MCPM)

• Ch. 1 General Billing Guidelines
• Ch. 12, §40.1 Definition of a Global Surgical Package
• Ch. 12, §40.2 Billing Requirements for Global Surgeries
• Ch. 12, §40.4 Payment for Terminated Procedures
• Ch. 12, §40.6 Claims for Multiple Surgeries
• Ch. 12, §40.7 Claims for Bilateral Surgeries
• Ch. 12, §90.3 Physicians’ Services Performed in Ambulatory Surgical Centers (ASC)
• Ch. 14, Ambulatory Surgical Centers
• Ch. 15, §260 Ambulatory Surgical Center Services
• Ch. 23 Fee Schedule Administration and Coding Requirements
• Ch. 30, §50 Advance Beneficiary Notice of Non-coverage (ABN)

IOM, Pub. 100-08, Medicare Program Integrity Manual (MPIM)

• Ch. 3 Verifying Potential Errors and Taking Corrective Actions
• Ch. 13, §13.5.4 Reasonable and Necessary Provisions in LCDs

CMS Coding Policies

• National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services Ch. 1, General Correct Coding Policies. Ch. 5, Surgery: Respiratory, Cardiovascular, Hemic and Lymphatic Systems (CPT Codes 30000-39999), Section D Cardiovascular System

Local Coverage Determination (LCD)

• L33575 Varicose Veins of the Lower Extremity, Treatment of
• L34010 Treatment of Varicose Veins of the Lower Extremity. Effective Date: 10/1/2015. Retired Date: 10/16/25
• L34082 Varicose Veins of the Lower Extremity, Treatment of
• L34209 Treatment of Varicose Veins of the Lower Extremity
• L34536 Treatment of Varicose Veins of the Lower Extremity
• L34924 Treatment of Varicose Veins of the Lower Extremity
• L38720 Treatment of Varicose Veins of the Lower Extremity
• L39121 Treatment of Varicose Veins of the Lower Extremities

Local Coverage Article (LCA)

• A52870 Billing and Coding: Treatment of Varicose Veins of the Lower Extremity
• A55229 Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities
• A56914 Billing and Coding: Treatment of Varicose Veins of the Lower Extremities
• A57305 Billing and Coding: Varicose Veins of the Lower Extremity, Treatment of
• A57706 Billing and Coding: Treatment of Varicose Veins of the Lower Extremities
• A57707 Billing and Coding: Treatment of Varicose Veins of the Lower Extremities. Effective 12/1/2019. Retired Date: 10/16/25
• A58250 Billing and Coding: Treatment of Varicose Veins of the Lower Extremity
• A58876 Billing and Coding: Treatment of Varicose Veins of the Lower Extremities

Last Updated Sep 4, 2026