Independence has reviewed the policy for endovenous mechanochemical ablation (CPT^® codes 36473, 36474) as part of the policy maintenance process and procedure code review. Medical Policy #11.02.01p: Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence is being updated to reflect that mechanochemical ablation will be considered experimental/investigational for commercial members. This policy was posted as a Notification on December 27, 2017, and will go into effect March 27, 2018.

Endovenous mechanochemical ablation is a minimally invasive treatment for varicose veins, combining mechanical and chemical modalities. The procedure involves the use of a special percutaneous infusion catheter, which contains a rotating wire, providing endovenous mechanical destruction. Simultaneously, a U.S. Food and Drug Administration-approved sclerosing agent (e.g., sodium tetradecyl sulfate) is administered in order to enhance occlusion of the vein.

Based on the available peer-reviewed literature and medical society guidelines, these previously eligible services, identified by the following procedure codes, which went into effect January 1, 2017, have been determined to be experimental/investigational for our commercial HMO, POS, and PPO members because the safety and/or effectiveness of these services cannot be established by review of the available published peer-reviewed literature:

• CPT^® 36473: Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated
• CPT^® 36474: Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

CPT Copyright 2016 American Medical Association. All rights reserved. CPT^® is a registered trademark of the American Medical Association.