Certificate of Medical Necessity /
Treatments for Varicose Veins/Venous Insufficiency
Please fax completed CMN forms and other required documentation
(i.e., physician history and physical, ultrasound report). / Statewide Fax Number:1.813.806.1233
Section A

Physician Information

Name:

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BCBSF Number:

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National Provider Identifier (NPI):

Street Address:

City:

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County:

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State:

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ZIP:

Telephone Number:

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Fax Number:

Contact Name:

Member Information

Last Name: / First Name:
Member/Contract Number (alpha and numeric): / Date of Birth: / Age:

Procedure Information

Procedure Code: / Procedure Description:
ICD-9 Code: / Diagnosis Description:
What treatment modality is being used (i.e. ablation, sclerotherapy)?
What types of veins are being treated (i.e. accessory, tributary, etc.)?
What size are the veins?
SectionB

Complete ALL the following questions. For bulleted questions,check the appropriate indicator(s). Use the comments field on the last page to provide details.

Yes No / Is the request for one of the following techniques and conditions?
Sclerotherapy of perforator, greater or lesser saphenous, or accessory saphenous veinsOR
Sclerotherapy of isolated tributary veins without prior or concurrent treatment of saphenous veins OR
Stab avulsion, hook phlebectomy, or transilluminated powered phlebectomy of perforator, greater or lesser saphenous, or accessory saphenous veinsOR
Endovenous radiofrequency or laser ablation of tributary veins OR
Endovenous cryoablation of any veinOR
Endomechanical ablative approach (e.g. ClariVein™ Catheter)OR
Is the request for treatment of telangiectasia such as spider veins, angiomata, or hemangiomata?OR
Is the request for ultrasound (US) guidance for sclerotherapy of the non-saphenous veins (varicose tributaries)?
Yes No / Is the request for treatment of the greater or lesser saphenous veins?
Are ALL of the following criteria met for the treatment of the greater or lesser saphenous veins by surgery (ligation and stripping) or endovenous radiofrequency or laser ablation for symptomatic varicose veins/venous insufficiency?
There is demonstrated saphenous reflux AND
The varicosities are at least 3 millimeters in size AND
There is documentation of one or more of the following indications:
Ulceration secondary to venous stasis that fails to respond to compressive therapyOR
Recurrent superficial thrombophlebitis that fails to respond to compressive therapyOR
Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity OR
Persistent pain, swelling, itching, burning, or other symptoms are associated with saphenous reflux, AND the symptoms significantly interfere with activities of daily living, AND conservative management including compression therapy for at least 3 months has not improved the symptoms.
Yes No / Is the request for treatment of accessory saphenous veins?
Are ALL of the following criteria met for the treatment of accessory saphenous veins by surgery (ligation and stripping) or endovenous radiofrequency or laser ablation for symptomatic varicose veins/venous insufficiency?
The greater or lesser saphenous veins had been previously eliminated (at least 3 months)AND
There is demonstrated accessory saphenous refluxAND
The varicosities are at least 3 millimeters in size AND
There is documentation of one or more of the following indications:
Ulceration secondary to venous stasis that fails to respond to compressive therapyOR
Recurrent superficial thrombophlebitis that fails to respond to compressive therapyOR
Hemorrhage or recurrent bleeding episodes from a ruptured superficial varicosity OR
Persistent pain, swelling, itching, burning, or other symptoms are associated with saphenous reflux, AND the symptoms significantly interfere with activities of daily living, AND conservative management including compression therapy for at least 3 months has not improved the symptoms.
Yes No / Is the request for treatment of symptomatic varicose tributaries?
Is one of the following treatments a component of the treatment for symptomatic varicose tributaries when performed either at the same time or following prior treatment (surgical, radiofrequency or laser) of the saphenous veins?
Stab avulsion
Hook phlebectomy
Sclerotherapy
Transilluminated powered phlebectomy
Yes No / Is the request for treatment of incompetent perforator veins?
Are ALL of the following criteria met for surgical ligation (including subfascial endoscopic perforator surgery) or endovenous radiofrequency or laser ablation of incompetent perforator veins as a treatment of leg ulcers associated with chronic venous insufficiency?
There is demonstrated perforator refluxAND
The varicosities are at least 3 millimeters in size AND
The superficial saphenous veins (greater, lesser, or accessory saphenous and symptomatic varicose tributaries) have been previously eliminatedAND
Ulcers have not resolved following combined superficial vein treatment and compression therapy for at least 3 monthsAND
The venous insufficiency is not secondary to deep venous thromboembolism.

Comments:

My signature below certifies that the information submitted on this form is accurate and these services are medically necessary.

Ordering Physician’s Signature: / Date:

Certificate of Medical Necessity:Treatments for Varicose Veins/Venous Insufficiency1