Download GM Varicose Veins Policy - North West Commissioning Support Unit

Greater Manchester EUR Policy
Statement on:
Varicose Veins
GM Ref: GM003
Version: 2.0 (March 2017)
Commissioning Statement
Varicose Veins
Policy
Inclusion
Criteria
All patients should be given advice on lifestyle changes, exercise and skin care.
Secondary care referral and management is commissioned for the following:
Urgent referral for bleeding
•
They are bleeding from a varicosity.
•
They have bled from a varicosity and are at risk of bleeding again.
Funding Mechanism
Monitored approval: Referrals may be made in line with the criteria without seeking
funding. NOTE: May be the subject of contract challenges and/or audit of cases
against commissioned criteria.
Severe varicose veins
Referral to a vascular service for patients with severe varicose veins – these are
varicose veins that are associated with any one of the following:
•
They have an ulcer which is progressive and/or painful.
•
They have recurrence of an ulcer
•
They have an ulcer which has failed to respond to 12 weeks or more of active
treatment or is deteriorating despite treatment
•
Progressive skin changes indicative of venous disease that may benefit from
surgery.
Funding Mechanism
Monitored approval: Referrals may be made in line with the criteria without seeking
funding. NOTE: May be the subject of contract challenges and/or audit of cases
against commissioned criteria. Except for Wigan Borough CCG which will be:
Individual prior approval provided the patient meets the above criteria. Requests
should be submitted with all relevant supporting evidence, which must be provided
with the request.
Moderate varicose veins
Patients with:
•
Atrophy blanche with hemosiderin deposition.
•
Extensive tortuous varicose veins of the whole lower limb (indicative of long
saphenous insufficiency) who would be considered at high risk of bleeding from
minor external trauma.
Funding Mechanism
Individual prior approval provided the patient meets the above criteria. Requests
should be submitted with all relevant supporting evidence, which must be provided
with the request.
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Secondary care management
On referral, duplex ultrasound to confirm the diagnosis and determine the presence
and extent of truncal reflux should be undertaken prior to invasive treatment being
undertaken.
Treatment should be offered as follows:
1. First offer endothermal ablation (NICE IPG8 and 52).
2. If endothermal ablation is unsuitable offer ultrasound guided foam sclerotherapy
(NICE IPG440).
3. If ultrasound guided foam sclerotherapy is unsuitable then offer surgery.
NOTE:
•
If incompetent varicose tributaries are to be treated, consider treating them at the
same time.
•
If compression hosiery or bandaging is offered do not use for more than 7 days.
•
Do not use compression hosiery to treat varicose veins unless interventional
treatment is not suitable.
•
Do not carry out interventional treatment of varicose veins during pregnancy except
in exceptional circumstances.
Clinical
Clinicians can submit an Individual Funding Request (IFR) outside of this guidance if
Exceptionality they feel there is a good case for exceptionality.
Exceptionality means ‘a person to which the general rule is not applicable’. Greater
Manchester sets out the following guidance in terms of determining exceptionality;
however the over-riding question which the IFR process must answer is whether each
patient applying for exceptional funding has demonstrated that his/her circumstances
are exceptional. A patient may be able to demonstrate exceptionality by showing that
s/he is:
•
Significantly different to the general population of patients with the condition in
question.
and as a result of that difference
•
Policy
Exclusions
They are likely to gain significantly more benefit from the intervention than might be
expected from the average patient with the condition.
Treatment/procedures undertaken as part of an externally funded trial or as a part of
locally agreed contracts / or pathways of care are excluded from this policy, i.e. locally
agreed pathways take precedent over this policy (the EUR Team should be informed of
any local pathways for this exclusion to take effect).
NOTE: Thread veins and spider naevus / telangiectasia are included within the GM
Common Benign Skin Lesions policy.
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Contents
Commissioning Statement ........................................................................................................................ 2
Policy Statement ...................................................................................................................................... 5
Equality & Equity Statement ..................................................................................................................... 5
Governance Arrangements....................................................................................................................... 5
Aims and Objectives ................................................................................................................................. 5
Rationale behind the policy statement ...................................................................................................... 6
Treatment / Procedure.............................................................................................................................. 6
Epidemiology and Need ........................................................................................................................... 6
Adherence to NICE Guidance .................................................................................................................. 6
Audit Requirements .................................................................................................................................. 7
Date of Review .........................................................................................................................................7
Glossary ...................................................................................................................................................7
References ...............................................................................................................................................7
Governance Approvals ............................................................................................................................. 7
Appendix 1 – Evidence Review ................................................................................................................ 9
Appendix 3 – Diagnostic and Procedure Codes...................................................................................... 14
Appendix 4 – Version History ................................................................................................................. 16
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Policy Statement
Greater Manchester Shared Services (GMSS) Effective Use of Resources (EUR) Policy Team in
conjunction with GM EUR Steering Group have developed this policy on behalf of Clinical
Commissioning Groups (CCGs) within Greater Manchester, who will commission treatments/procedures
in accordance with the criteria outlined in this document.
In creating this policy GMSS has reviewed this clinical condition and the options for its treatment. It has
considered the place of this treatment in current clinical practice, whether scientific research has shown
the treatment to be of benefit to patients, (including how any benefit is balanced against possible risks)
and whether its use represents the best use of NHS resources.
This policy document outlines the arrangements for funding of this treatment for the population of
Greater Manchester.
This policy follows the principles set out in the ethical framework that govern the commissioning of NHS
healthcare and those policies dealing with the approach to experimental treatments and processes for
the management of individual funding requests (IFR).
Equality & Equity Statement
GMSS/CCGs have a duty to have regard to the need to reduce health inequalities in access to health
services and health outcomes achieved, as enshrined in the Health and Social Care Act 2012.
GMSS/CCG is committed to ensuring equality of access and non-discrimination, irrespective of age,
gender, disability (including learning disability), gender reassignment, marriage and civil partnership,
pregnancy and maternity, race, religion or belief, gender or sexual orientation. In carrying out its
functions, GMSS/CCG will have due regard to the different needs of protected characteristic groups, in
line with the Equality Act 2010. This document is compliant with the NHS Constitution and the Human
Rights Act 1998. This applies to all activities for which they are responsible, including policy
development, review and implementation.
In developing policy the GMSS Policy Team will ensure that equity is considered as well as equality.
Equity means providing greater resource for those groups of the population with greater needs without
disadvantage to any vulnerable group.
The Equality Act 2010 states that we must treat disabled people as more equal than any other protected
characteristic group. This is because their ‘starting point’ is considered to be further back than any other
group. This will be reflected in GMSS evidencing taking ‘due regard’ for fair access to healthcare
information, services and premises.
An Equality Analysis has been carried out on the policy.
Analysis, please contact [email protected].
For more information about the Equality
Governance Arrangements
Greater Manchester EUR policy statements will be ratified by the Greater Manchester Association
Governing Group (AGG) prior to formal ratification through CCG Governing Bodies. Further details of
the governance arrangements can be found in the Greater Manchester EUR Operational Policy.
Aims and Objectives
This policy document aims to ensure equity, consistency and clarity in the commissioning of
treatments/procedures by CCGs in Greater Manchester by:
•
reducing the variation in access to treatments/procedures.
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•
ensuring that treatments/procedures are commissioned where there is acceptable evidence of
clinical benefit and cost-effectiveness.
•
reducing unacceptable variation in the commissioning of treatments/procedures across Greater
Manchester.
•
promoting the cost-effective use of healthcare resources.
Rationale behind the policy statement
To consolidate current commissioning arrangements across Greater Manchester and to begin the shift
towards commissioning these services in line with NICE CG168, which radically altered the treatment
pathway for varicose veins. This policy has been developed to reflect the updated pathway.
Treatment / Procedure
In some people varicose veins are asymptomatic or cause only mild symptoms, but in others they cause
pain, aching or itching and can have a significant effect on their quality of life. Varicose veins can cause
skin changes, varicose eczema and varicose ulceration. Bleeding or thrombophlebitis may also occur.
Previous PCT commissioning policies for varicose veins required that all patients had undergone
conservative management including the use of compression stockings and that only those with severe
varicose veins should be referred for surgery.
This guidance recognises a desire to move towards commissioning a service for the treatment of
varicose veins based on NICE CG168 but recognises that before this can happen there is a need to
ensure that all stages of the pathway identified in NICE IPG168 are available locally and that patients
are managed in line with that guidance. Until the pathway and supporting commissioning work is
completed then patients should be referred using the criteria listed in this policy.
Epidemiology and Need
Varicose veins are dilated, often palpable subcutaneous veins with reversed blood flow. They are most
commonly found in the legs. Estimates of the prevalence of varicose veins vary. Visible varicose veins
in the lower limbs are estimated to affect at least a third of the population. Risk factors for developing
varicose veins are unclear, although prevalence rises with age and they often develop during pregnancy.
In some people, varicose veins are asymptomatic or cause only mild symptoms, but in others they cause
pain, aching or itching and can have a significant effect on their quality of life.
Varicose veins may become more severe over time and can lead to complications such as changes in
skin pigmentation, bleeding or venous ulceration. It is not known which people will develop more severe
disease but it is estimated that 3-6% of people who have varicose veins in their lifetime will develop
venous ulcers.
Health Technology Assessment NHS R&D HTA Programme: Randomised clinical trial, observational
study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial) estimated
that the prevalence of visible varicose veins in Europe and the USA is approximately 25-30% for adult
women and approximately 15% for men.
Adherence to NICE Guidance
In drafting these guidelines it was noted that NICE CG168 recommends that all symptomatic varicose
veins should be referred for investigation and, where appropriate, treatment. Current resources cannot
meet the demand that this would generate either in the commissioning costs associated with
implementing the NICE pathway, or in the capacity to undertake Doppler examinations etc. These
guidelines are intended as a holding position whilst the required pathway and contracting changes have
been made to enable seamless adoption of NICE CG168.
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Audit Requirements
There is currently no national database. Service providers will be expected to collect and provide audit
data on request.
Date of Review
One year from the date of approval by Greater Manchester Association Governing Group thereafter at a
date agreed by the Greater Manchester EUR Steering Group (unless stated this will be every 2 years).
When this policy is reviewed all available additional data on outcomes will be included in the review and
the policy updated accordingly.
Glossary
Term
Meaning
Endothermal Ablation
Energy from either from high-frequency radio waves (radiofrequency ablation) or
lasers (endovenous laser treatment) is used to seal the affected veins.
Exceptionality
A person to which the general rule is not applicable (see policy exclusions
sections above for a detailed definition).
Foam Sclerotherapy
The injection of a special foam into the veins, which scars the veins and seals
them closed.
Varicose Veins
Varicose veins are dilated, often palpable subcutaneous veins with reversed
blood flow. They are most commonly found in the legs.
References
1. Greater Manchester Effective Use of Resources Operational Policy
Governance Approvals
Name
Date Approved
Greater Manchester Effective Use of Resources Steering Group
v1.0: 17/09/2014
v2.0: 16/03/2016
Greater Manchester Chief Finance Officers / Greater Manchester Directors of
Commissioning
v1.0: 15/12/2014
v2.0: 14/02/2017
Greater Manchester Association Governing Group
v1.0: 06/01/2015
v2.0: 07/03/2017
Bury Clinical Commissioning Group
04/03/2015
Bolton Clinical Commissioning Group
27/03/2015
Heywood, Middleton & Rochdale Clinical Commissioning Group
20/03/2015
Central Manchester Clinical Commissioning Group
05/03/2015
North Manchester Clinical Commissioning Group
13/01/2015
Oldham Clinical Commissioning Group
06/01/2015
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Salford Clinical Commissioning Group
06/01/2015
South Manchester Clinical Commissioning Group
11/03/2015
Stockport Clinical Commissioning Group
25/02/2015
Tameside & Glossop Clinical Commissioning Group
22/04/2015
Trafford Clinical Commissioning Group
17/03/2015
Wigan Borough Clinical Commissioning Group
04/03/2015
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Appendix 1 – Evidence Review
Varicose Veins
GM003
Search Strategy
The following databases are routinely searched: NICE Clinical Guidance and full website search; NHS
Evidence and NICE CKS; SIGN; Cochrane; York; BMJ Clinical Evidence; and the relevant royal college
websites. A Medline / Open Athens search is undertaken where indicated and a general google search
for key terms may also be undertaken. The results from these and any other sources are included in the
table below. If nothing is found on a particular website it will not appear in the table below:
Database
Result
NICE (includes NHS
Evidence)
•
•
•
•
NICE CG168: Varicose veins: diagnosis and management
NICE IPG8: Radiofrequency ablation of varicose veins (not cited here)
NICE IPG52: Endovenous laser treatment of the long saphenous vein
(not cited here)
NICE IPG440: Ultrasound-guided foam sclerotherapy for varicose veins
(not cited here)
SIGN
SIGN 120: Management of chronic venous leg ulcers - A national clinical
guideline (not cited here)
Cochrane
Cochrane Collaboration: Compression stockings for the initial
treatment of varicose veins in patients without venous ulceration,
Shingler S et al, The Cochrane library 2011, issue 11
York
A systematic review and meta-analysis of the treatments of varicose
veins, MH Murad, F Coto-Yglesias, M Zumaeta-Garcia, MB Elamin, MK
Duggirala, PJ Erwin, VM Montori, and P Gloviczki., Review published: 2011
BMJ Clinical Evidence
BMJ Clinical Evidence Review: Varicose Veins, Paul V Tisi, based on
January 2010 search
BMJ Best Practice
Not undertaken due to number of results found elsewhere.
General Search (Google)
Gonadal Vein Embolization: Treatment of Varicocele and Pelvic
Congestion Syndrome, Mark A. Bittles, M.D.,1 and Eric K. Hoffer, M.D.2
(not cited here)
See also GM EUR Pelvic Vein Embolisation in the management of varicose
veins policy
Medline / Open Athens
•
•
•
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Randomized trial comparing endovenous laser ablation of the
great saphenous vein with high ligation and stripping in patients
with varicose veins: Short-term results, Lars H. Rasmussen, MD,
DMSC, Lars Bjoern, MD, Martin Lawaetz, BS, Allan Blemings, MSc,
Birgit Lawaetz, RN, and Bo Eklof, MD, PhD, Naestved and Roskilde,
Denmark, 2007
Evidence based clinical practice guidelines: chronic wounds of the
lower extremity, American society of plastic surgeons, 2007 (not cited
here)
Randomised clinical trial, observational study and assessment of
cost-effectiveness of the treatment of varicose veins (REACTIV
trial), JA Michaels et al, Health Technology Assessment NHS R&D HTA
Programme, April 2006 (not cited here)
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Evidence listed but not cited has been send to indirectly inform the development of this policy but does
not relate directly to the content / criteria.
Summary of the evidence
There were a lot of evidence reviews and guidelines covering this topic. However, the papers cited
within these were often of low quality, i.e. Level 3-5.
The evidence
Levels of evidence
Level 1
Meta-analyses, systematic reviews of randomised controlled trials
Level 2
Randomised controlled trials
Level 3
Case-control or cohort studies
Level 4
Non-analytic studies e.g. case reports, case series
Level 5
Expert opinion
1.
LEVEL 1: SYSTEMATIC REVIEW
NICE CG168: Varicose veins: diagnosis and management
NICE carried out a review of the evidence and based their recommendations on the best available
evidence whilst acknowledging that a lot more evidence based research was needed.
The evidence review for the guideline showed a lack of high quality evidence on the natural progression
of varicose veins. It found that the current evidence for the use of compression hosiery was weak and
that the evidence for its use after interventional treatment was unclear.
It found one small scale study (n=50) on the use and timing of tributary treatment after truncl
endothermal ablation.
It also found that most of the research into the optimum treatment for varicose veins involved patients at
stage C2 and C3 so little is known of the relative efficacies of the treatments at the more severe stages
of the disease.
2.
LEVEL 1: SYSTEMATIC REVIEW AND META-ANALYSIS
A systematic review and meta-analysis of the treatments of varicose veins, MH Murad, F
Coto-Yglesias, M Zumaeta-Garcia, MB Elamin, MK Duggirala, PJ Erwin, VM Montori, and P
Gloviczki., Review published: 2011
The review found that, based on low quality evidence, available treatments for varicose veins appeared
safe and surgery appeared effective long term. Less invasive treatments caused less periprocedural
disability and pain but their effectiveness was supported only by short-term studies. These conclusions
require some caution in interpretation due to large differences between the included studies.
3.
LEVEL 1: SYSTEMATIC REVIEW
BMJ Clinical Evidence Review: Varicose Veins, Paul V Tisi, Based on January 2010 search
They found 39 systematic reviews, RCTs, or observational studies that met their inclusion criteria. They
performed a GRADE evaluation of the quality of evidence for interventions and they presented
information relating to the effectiveness and safety of the following interventions: compression stockings,
endovenous laser, injection sclerotherapy, radiofrequency ablation, self-help (advice, avoidance of tight
clothing, diet, elevation of legs, exercise), and surgery (stripping, avulsion, powered phlebectomy).
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4.
LEVEL 2: RANDOMISED CONTROLLED TRIAL
Randomized trial comparing endovenous laser ablation of the great saphenous vein with
high ligation and stripping in patients with varicose veins: Short-term results, Lars H.
Rasmussen, MD, DMSC, Lars Bjoern, MD, Martin Lawaetz, BS, Allan Blemings, MSc, Birgit
Lawaetz, RN, and Bo Eklof, MD, PhD, Naestved and Roskilde, Denmark, 2007
ABSTRACT:
Background: Endovenous laser (EVL) ablation of the great saphenous vein (GSV) is thought to
minimize postoperative morbidity and reduce work loss compared with high ligation and stripping (HL/S).
However, the procedures have not previously been compared in a randomized trial with parallel groups
where both treatments were performed in tumescent anesthesia on an out-patient basis.
Methods: Patients with varicose veins due to GSV insufficiency were randomized to either EVL (980
nm) or HL/S in tumescent anesthesia. Miniphlebectomies were also performed. Patients were examined
preoperatively and at 12 days, and 1, 3, and 6 months postoperatively. Sick leave, time to normal
physical activity, pain score, use of analgesics, Aberdeen score, Medical Outcomes Study Short Form36 quality-of-life score, Venous Clinical Severity Score (VCSS), and complication rates were
investigated. The total cost of the procedures, including lost wages and equipment, was calculated. Cost
calculations were based on the standard fee for HL/S with the addition of laser equipment and the
standard salary and productivity level in Denmark.
Results: A follow-up of 6 months was achieved in 121 patients (137 legs). The groups were well
matched for patient and GSV characteristics. Two HL/S procedures failed, and three GSVs recanalized
in the EVL group. The groups experienced similar improvement in quality-of-life scores and VCSS score
at 3 months. Only one patient in the HL/S group had a major complication, a wound infection that was
treated successfully with antibiotics. The HL/S and EVL groups did not differ in mean time to resume
normal physical activity (7.7 vs 6.9 calendar days) and work (7.6 vs 7.0 calendar days). Postoperative
pain and bruising was higher in the HL/S group, but no difference in the use of analgesics was recorded.
The total cost of the procedures, including lost wages, was €3084 ($3948 US) in the HL/S and €3396
($4347 US) in the EVL group.
Conclusions: This study suggests that the short-term efficacy and safety of EVL and HL/S are similar.
Except for slightly increased postoperative pain and bruising in the HL/S group, no differences were
found between the two treatment modalities. The treatments were equally safe and efficient in
eliminating GSV reflux, alleviating symptoms and signs of GSV varicosities, and improving quality of life.
Long-term outcomes, particularly with respect to recurrence rates, shall be investigated in future studies,
including the continuation of the present.
5.
LEVEL 1: SYSTEMATIC REVIEW
Cochrane Collaboration: Compression stockings for the initial treatment of varicose veins
in patients without venous ulceration, Shingler S et al, The Cochrane library 2011, issue 11
Background: Compression hosiery or stockings are often the first line of treatment for varicose veins in
people without either healed or active venous ulceration. Evidence is required to determine whether the
use of compression stockings can effectively manage and treat varicose veins in the early stages.
Objectives: To assess the effectiveness of compression stockings for the initial treatment of varicose
veins in patients without healed or active venous ulceration.
Search methods: The Cochrane Peripheral Vascular Disease Group searched their Specialised
Register (last searched 31 May 2011) and CENTRAL (2011, Issue 2). In addition, the reference lists of
relevant articles were searched. Authors of ongoing and current trials were contacted. There were no
language restrictions.
Selection criteria: Randomised controlled trials (RCTs) were included if they involved participants
diagnosed with primary trunk varicose veins without healed or active venous ulceration (Clinical,
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Etiology, Anatomy, Pathophysiology (CEAP) classification C2 to C4). Included trials assessed
compression stockings versus no treatment, compression versus placebo stockings, or compression
stockings + drug intervention versus drug intervention alone. Trials comparing different lengths and
pressures of stockings were also included. Trials involving other types of treatment for varicose veins
(either as a comparator to stockings or as an initial non-randomised treatment), including sclerotherapy
and surgery, were excluded.
Data collection and analysis: Two authors assessed the trials for inclusion and quality (SS and LR).
SS extracted the data, which were checked by LR. Attempts were made to contact trial authors where
missing or unclear data were present.
Main results: Seven studies involving 356 participants with varicose veins without healed or active
venous ulceration were included. Different levels of pressure were exerted by the stockings in the
studies, ranging from 10 to 50 mmHg. One study assessed compression hosiery versus no compression
hosiery. The other six compared different types or pressures of stockings. The methodological quality of
all included trials was unclear, mainly because of inadequate reporting. The symptoms subjectively
improved with the wearing of stockings across trials that assessed this outcome, but these assessments
were not made by comparing one randomised arm of a trial with a control arm and are therefore subject
to bias. Meta-analyses were not undertaken due to inadequate reporting and actual or suspected high
levels of heterogeneity.
Authors’ conclusions: There is insufficient, high quality evidence to determine whether or not
compression stockings are effective as the sole and initial treatment of varicose veins in people without
healed or active venous ulceration, or whether any type of stocking is superior to any other type. Future
research should consist of a large RCT of participants with trunk varices either wearing or not wearing
compression stockings to assess the efficacy of this intervention. If compression stockings are found to
be beneficial, further studies assessing which length and pressure is the most efficacious could then
take place.
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Appendix 2 – Venous Clinical Severity Score
Varicose Veins
GM003
Attribute
Absent = 0
Mild = 1
Moderate = 2
Severe = 3
Pain
None
Occasional, not
restricting activity or
requiring pain
medication
Daily moderate activity
limitation; occasional
pain medication
Daily, severe limiting
activities or requiring
regular use of pain
medications
Varicose Veins
None
Few scattered
Multiple; great
saphenous veins,
confined to calf and
thigh
Extensive; thigh and calf
or great and small
saphenous distribution
Venous Edema
None
Evening ankle swelling
only
Afternoon swelling,
above ankle
Morning swelling above
ankle and requiring
activity change,
elevation
Skin Pigmentation
None
Diffuse, but limited in
area and old (brown)
Diffuse over most of
gaiter distribution (lower
third) or recent
pigmentation (purple)
Wider distribution
(above lower third) plus
recent pigmentation
Inflammation
None
Mild cellulitis, limited to
marginal area around
ulcer
Moderate cellulitis,
involves most of (lower
third)
Severe cellulitis (lower
third and above) or
significant
Induration
None
Focal, circummalleolar
Medial or lateral, less
than lower third of leg
Entire lower third of leg
or more
Number of Active
Ulcers
0
1
2
>2
Active Ulcer
Duration
None
<3 months
>3 months, <1 year
Not healed>1 Year
Active Ulcer
Diameter
None
<2
2-6
>6
Compression
Therapy
Not used or
patient not
compliant
Intermittent use of
stockings
Wears elastic stocking
most days
Full compliance,
stockings + elevation
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Appendix 3 – Diagnostic and Procedure Codes
Varicose Veins
GM003
(All codes have been verified by Mersey Internal Audit’s Clinical Coding Academy)
GM003 - Varicose Veins Policy
Combined operations on primary long saphenous vein
L84.1
Combined operations on primary short saphenous vein
L84.2
Combined operations on primary long and short saphenous vein
L84.3
Combined operations on recurrent long saphenous vein
L84.4
Combined operations on recurrent short saphenous vein
L84.5
Combined operations on recurrent long and short saphenous vein
L84.6
Other specified combined operations on varicose vein of leg
L84.8
Unspecified combined operations on varicose vein of leg
L84.9
Ligation of long saphenous vein
L85.1
Ligation of short saphenous vein
L85.2
Ligation of recurrent varicose vein of leg
L85.3
Other specified ligation of varicose vein of leg
L85.8
Unspecified ligation of varicose vein of leg
L85.9
Injection of sclerosing substance into varicose vein of leg NEC
L86.1
Ultrasound guided foam sclerotherapy for varicose vein of leg
L86.2
Unspecified injection into varicose vein of leg
L86.9
Stripping of long saphenous vein
L87.1
Stripping of short saphenous vein
L87.2
Avulsion of varicose vein of leg
L87.4
Local excision of varicose vein of leg
L87.5
Transilluminated powered phlebectomy of varicose vein of leg
L87.7
Other specified other operations on varicose vein of leg
L87.8
Percutaneous transluminal laser ablation of long saphenous vein
L88.1
Radiofrequency ablation of varicose vein of leg
L88.2
Percutaneous transluminal laser ablation of varicose vein of leg NEC
L88.3
Unspecified transluminal operations on varicose vein of leg
L88.9
With the following ICD-10 diagnosis code(s):
Varicose veins of lower extremities with ulcer
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I83.0
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Varicose veins of lower extremities with inflammation
I83.1
Varicose veins of lower extremities with both ulcer and inflammation
I83.2
Varicose veins of lower extremities without ulcer or inflammation
I83.9
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Appendix 4 – Version History
Varicose Veins
GM003
The latest version of this policy can be found here: GM Varicose Veins policy
Version Date
Summary of Changes
0.1
23/10/2013
Initial Draft for consideration by GM EUR Steering Group
0.2
10/02/2014
•
•
0.3
24/03/2014
Amendments made by GM EUR Steering Group on 19/03/2014:
• Criteria for commissioning revised in accordance with GM EUR Steering
Group recommendations.
• Removal of “Varicose Vein Referral Threshold Tool”
– Appendix 2
• Inclusion of “GM013 Benign Skin Lesion EUR Policy” under section 12 links to other policies.
0.4
08/04/2014
•
•
0.5
Appendix 2 added “Varicose Vein Referral Threshold Tool”
Thread veins and Spider Naevus/Telangiectasia are included within the
GM013 Dermatology Minor Surgery policy inserted in policy exclusions
section.
Statement regarding treating disabled people as more equal than other
protected characteristic groups added to Equality and Equity section.
Ratification through CCG Governing Bodies added to ‘Governance
Arrangements’.
28/05/2014
Amendments made by GM EUR Steering Group on 21/05/2014:
• Aberdeen Score changed to Venous Clinical Severity Score.
• The first 2 bullet points in the mandatory criteria should be specified as an
urgent referral.
• Reference to NICE 168 guidance further defined, and includes an
explanation of why the policy does not fully comply with NICE guidance.
• Appendix 2: Venous Clinical Severity Score added.
• Draft policy approved for consultation following the above amendments.
• Policy published for consultation from 09/07/2014 to 03/09/2014.
09/07/2014
Feedback from consultation reviewed by the GM EUR Steering Group.
amendments required.
17/09/2014
Policy approved by GM EUR Steering Group.
0.6
08/10/2014
Branding Changed following creation of North West CSU on 01/10/2014.
1.0
17/09/2014
Policy approved by GM EUR Steering Group.
1.1
27/03/2015
Bolton CCG adopted funding mechanism of IPA for all requests.
23/06/2015
•
•
Variance column removed and funding mechanism column added to table.
Format of funding mechanism changed.
05/04/2016
•
List of diagnostic and procedure codes in relation to this policy added as
Appendix 3.
Policy changed to Greater Manchester Shared Services template and
references to North West Commissioning Support Unit changed to Greater
Manchester Shared Services.
1.2
•
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19/04/2016
•
•
Funding mechanism for Bolton CCG changed from Individual Prior Approval
for all requests to Monitored Approval for severe varicose veins and
Individual Prior Approval for moderate varicose veins – in line with the rest of
GM.
Wording for date of review amended to read “One year from the date of
approval by Greater Manchester Association Governing Group thereafter at
a date agreed by the Greater Manchester EUR Steering Group (unless
stated this will be every 2 years)” on ‘Policy Statement’ and section ‘13. Date
of Review’.
1.3
13/06/2016
Wigan CCG changed funding mechanism to Individual Prior Approval (IPA) for
severe varicose veins – to be adopted from 1st August 2016.
2.0
18/05/2016
The GM EUR Steering Group reviewed the policy and the following changes
were made:
• 'Severe Varicose Veins' section reworded as follows:
"All patients should be given advice on lifestyle changes, exercise and skin
care.
Secondary care referral and management is commissioned for the following:
Urgent Referral for Bleeding
• They are bleeding from a varicosity.
• They have bled from a varicosity and are at risk of bleeding again.
Severe Varicose Veins
Referral to a vascular service for patients with severe varicose veins – these
are varicose veins that are associated with any one of the following:
• They have an ulcer which is progressive and/or painful.
• They have recurrence of an ulcer
• They have an ulcer which has failed to respond to 12 weeks or more of
active treatment or is deteriorating despite treatment
• Progressive skin changes indicative of venous disease that may benefit
from surgery."
• First paragraph under 'Moderate Varicose Veins' sub-heading removed and
replaced with:
"Patients with:
• Atrophy blanche with hemosiderin deposition.
• Extensive tortuous varicose veins of the whole lower limb (indicative of
long saphenous insufficiency) who would be considered at high risk of
bleeding from minor external trauma.
Referral for the moderate group is via the IFR route for prior approval"
• Sub-heading added for clarity: ‘Secondary Care Management’
14/02/2017
Reviewed policy approved by GM CFOs / GM DOCs
07/03/2017
Reviewed policy approved by GM AGG
08/03/2017
•
•
Policy transferred to new template format.
Wording in 'Search Strategy' section in Appendix 1 amended for clarity
GM Varicose Veins Policy v2.0 FINAL
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