At the Vein Institute of NJ, we want your health to come first and foremost. We recognize that we live in a world where financial decisions play a major role in how we view our own health. We want you to be as informed as possible so your health and finances can best be served.
The question we get posed most often when it comes to cost is, “Will this vein treatment be covered by insurance?” As part of our core values of transparency, integrity and thoroughness, we have outlined below some of the concepts we believe the insurers evaluate when deciding if they should pay for a procedure. It is NEVER the physician who makes the determination of coverage—that is a decision made by your insurer based on the medical condition you have.
These guidelines represent the current policies of most insurers but are subject to change. These guidelines also use some complex medical jargon that you, as the patient, may find tongue-tying and a bit overwhelming. As always, we’re here to help. We can answer your questions during the initial consultation and clarify the terminology. In the meantime, this information should assist you with becoming more familiar with the insurance requirements that you and our doctors need to follow.
Vein Insurance Requirements
All of the insurance companies today (with a few exceptions) follow similar protocols. The following are , and Microphlebectomies
- Conservative Measures: Insurance companies want you to wear compression stockings for at least 3 months to see if these have a beneficial effect on your vein symptoms. We have found some insurance companies will eliminate the 3-month test period for patients with ulcers and/or bleeding.
- Venous Reflux Study: Within a 6-month timeframe, a doctor must document your medical history and check the blood flow in your legs using an ultrasound to see if there is reflux. Reflux occurs when the valves in the veins of the legs are not working properly inhibiting the return of blood to the heart from the lower extremities causing swelling, heaviness and, sometimes, varicose veins. The study should identify a vein diameter for the GSV (great saphenous vein) of 5.5 mm or more just below the saphenofemoral junction. Vein size for the SSV (small saphenous vein) should be 5.0 mm or more near the saphenopopliteal junction.
- Activities of Daily Living (ADL): Your daily activities should be significantly altered by your veins in order for the insurer to cover the cost of care. Knowing what you do for a living and how daily life has been affected is important. In addition, the report must show the ultrasound results, the fact that conservative measures (e.g., stockings) have not been successful, and the proposed treatment that you would need.
- Photo Documentation: It is important to provide visual images of the veins, their sizes, and what side of the body the veins are on.
CEAP Documentation: CEAP is a classification system for veins. While everyone may be a little different with their vein issues, this method provides a standard way to talk about veins. CEAP is required in all documentation.
- The CEAP acronym stands for:
- Clinical – what the patient’s veins look like
- Etiology – whether the problem is inherited or not
- Anatomy – which veins are involved
- Pathophysiology – in which direction the blood is flowing (either normal or abnormal flow) and whether blood flow is blocked
It’s important to note that sclerotherapy injections for spider veins are not covered by insurance when it is considered to be for cosmetic purposes. However, sclerotherapy may be covered for chronic venous insufficiency, bleeding veins or ulcers.
As you can see, there are many protocols that must be followed. These protocols should not be a deterrent to seeking the medical and health outcomes you desire. It is our job and our staff is well-versed in the current procedures. We are here to guide you through this.