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Most insurance companies will pay for a clinical evaluation and venous color duplex ultrasound exam, if indicated, for pain, tenderness, swelling, abnormal skin conditions, or varicose veins. The insurance companies vary considerably in terms of whether they will pay for treatment of various vein conditions. Most of the procedures which we perform are covered by the patients’ insurance or by other entities such as Medicare.

Many insurers require for treatment procedures that the patient still experiences significant pain, tenderness, swelling, or an abnormal skin condition due to venous disease that continues to cause a limitation of activities of daily living or significant other problems in spite of a course of “conservative” treatment.

Participating Status

We participate in the networks of the following third-party payors:

  • Aetna, including Coventry, Mailhandlers, and Meritain
  • Blue Cross/Blue Shield including BC Med Advantage Medicare replacement and the many state and regional Blue Cross plans such as BCBS of Tennessee, Anthem, Highmark, and many others
  • CIGNA
  • Coventry (Aetna)
  • Healthspring Medicare replacement
  • Humana/Care Choice commercial plans
  • Humana Military (Tricare)
  • Mailhandlers (Aetna)
  • Medicare, standard plans and Railroad Medicare
  • Meritain (Aetna)
  • Multiplan/PHCS/Beech Street
  • Tricare Prime and Tricare Standard
  • United Healthcare (UHC)
  • USA MCO
  • Walmart plans (most)
  • Wellcare

We see patients who are covered by a variety of other insurance plans which do not require a specific contracted network of physicians.

Out-of-Network?

Currently, we do not participate in some of the small insurance company plans. Additionally, some large insurance companies offer a multitude of plans and it is not feasible to contract for every one of these.  We can still evaluate and treat patients whose insurance is not contracted with us, but some of these insurance companies penalize the patient financially for seeking the best available care.

We are willing to share the financial burden with the patient by discounting our services to out-of-network patients since we know that care that is comparable to even some of our services requires considerable time and mileage driving to distant cities for evaluation, treatment, and long-term follow-up care.  As with much of life, the product or service which is the cheapest on the front end may not be the least expensive in the long run.

“Medical Necessity Criteria”

Insurers often use “medical necessity criteria” to determine whether they will pay for specific treatments for an individual. These criteria sometimes are reasonable, and other times the criteria are inappropriate medically or are written to avoid paying for medically appropriate care. Unfortunately, some insurers are reluctant to adopt evidence-based medical necessity criteria developed by nationally-prominent experts and expert medical societies.

Many insurance companies require a period of “conservative” treatment for one to three months before they will consider a request for approval to treat varicose vein conditions. This “conservative” care often includes local skin care, periodic elevation of the legs above the level of the heart, moderate exercise, calf muscle pump exercises, avoidance of prolonged sitting or standing when feasible, and routine daily use of medical grade elastic compression stockings or an alternate form of compression. We work to educate you about these requirements and to help you meet your insurer’s requirements.

We are actively involved in efforts to convince insurers to use recommendations and guidelines developed by the major national medical societies which are evidence-based and supported by experts in management of venous diseases.

Predetermination

Many, but not all, insurers will review medical records and a proposed plan of care which we submit to the insurer and will issue a “predetermination” that you meet that insurer’s criteria for treatment. If predetermination results in an authorization to treat, the insurer usually will pay its “allowed” amount (less any co-insurance and co-payment amounts) for the authorized procedures.

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    "Before graduating high school, I noticed a growing discomfort in my lower back region, leg pain, and severe pelvic pain. By age twenty-five, the pain had intensified beyond discomfort. As I was nearing thirty, my constant leg and pelvic pain interfered with my daily activities.…" -- R.C.

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