Prior Authorization Details

General Documentation Requirements for Vein Ablation and Related Services

Checklist of prior authorization request (PAR) information to include:

  • Doppler ultrasound results
  • Documentation stating presence or absence of DVT (deep vein thrombosis), aneurysm and/or tortuosity (when applicable)
  • Documented incompetence of the valves of the saphenous, perforator or deep venous systems consistent with the patient's symptoms and findings (when applicable)
  • Photographs if the clinical documentation received is inconclusive;
  • Patient's medical record must contain H&P examination supporting the diagnosis of symptomatic varicose veins (evaluation and complains) and the failure of an adequate trial of conservative management (before the initial procedure)

This checklist is not all inclusive; please submit any additional medical records that help support the medical necessity of the Hospital Outpatient Department service.

A facility or the beneficiary may submit the PAR and supplemental documentation via NGSConnex, esMD, fax or mail.

  • NGSConnex
  • esMD: Content type 8.5
  • Fax
    JK: 317-841-4530
    J6: 317-841-4528
  • Mail
    National Government Services, Inc.
    Attention: Medical Review Prior Authorization Request
    P.O. Box 7108
    Indianapolis, IN 46207-7108

Provider Contact Center Inquiry Line:

  • JK: 888-855-4356
  • J6: 877-702-0990

Related Content:

PAR decisions and the unique tracking numbers assigned for these services will be valid for 120 days. The decision date shall be counted as the first day of the 120 days. For example: if the PAR is affirmed on 1/1/2021, the PAR will be valid for dates of service through 4/30/2021. Otherwise, the provider will need to submit a new PAR.