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A cargo carrier is detachably engageable with a standard trailer hitch. The carrier is connected solely to the hitch, rather than to any portion of the vehicle body or bumper. A hitch tongue engaging portion is insertably engagable with the trailer hitch tongue, and a platform is attached to the engaging portion. The carrier is retained on the vehicle by the passage of a lockable clevis pin through registering holes in the tongue portion and the engaging portion. The carrier has the advantages of straightforward construction and tool-free attachment to the vehicle.
1. A carrier engageable with the trailer hitch tongue of a vehicle, said tongue having a longitudinally extending tongue portion of substantially uniform cross section, comprising:
a rectangular frame comprising two pairs of opposing side members;
means affixed to said frame for insertably engaging said tongue portion;
said engaging means being the sole means for connecting said carrier to said vehicle and for transferring the weight of said carrier to said vehicle;
at least one movable cargo support member disposed between one of said pairs of side members, said support member comprising a pair of ends one each adjacent to one side member of said one pair; and
means on said ends of said support member for attaching said support member to said one pair of side members so that said ends of said support member are movable along said one pair of side members;
wherein said support member is slidable along said one pair of side members, wherein each opposing side member comprises an interior wall, wherein said support member is insertable between said interior walls, and wherein said attachment means comprises an L-shaped plate abutting said interior wall and the top of said side member.
2. The invention according to claim 1, wherein said carrier is metal.
3. The invention according to claim 1, wherein said frame and said support member are tubular and are square in cross section.
4. The invention according to claim 1, wherein one of said pairs of side members comprises one side member proximal to said engaging means and another side member distal to said engaging means, and wherein said combination further comprises a frame support bar extending beneath a longitudinal axis of said frame from said engaging means to said distal side member.
This application is a continuation of application Ser. No. 591,038, filed 3/19/84, now abandoned.
I. Field of the Invention
The present invention is directed to a device for carrying cargo, and more particularly, to such a device attachable to a motor vehicle.
II. Description of the Prior Art
Cargo carriers which are attachable to motor vehicles have long been known. Some known cargo carriers are trailers, having one or more wheels which bear a substantial portion of the weight of the load carried by the carrier. Cargo trailers are conventionally attached to a motor vehicle through a trailer hitch affixed to the lower rear portion of the vehicle, generally at or below the vehicle bumper. Other cargo carriers comprise a rack or platform attached to one or more portions of the vehicle, such as a trailer hitch, the vehicle body or the vehicle bumper. Several carriers are known in which an end of a platform portion of the carrier is affixed to a portion of the vehicle above the trailer hitch, and a support member extends from the opposing end of the platform downward to the trailer hitch. The support member engages the trailer hitch to provide additional support for the platform.
Although the known cargo carriers generally function adequately for their intended purposes, their use on motor vehicles is often subject to several drawbacks. The known cargo carriers are of relatively complex structure, and are thereby rendered relatively expensive to produce. The support structures associated with these carriers require a substantial amount of time for assembly and for attachment to a vehicle. Moreover, a cargo carrier having a platform whose end must be affixed to the vehicle bumper or body may well damage that vehicle body or bumper when attached thereto.
The cargo carrying rack disclosed by Tartaglia, in U.S. Pat. No. 4,394,947, overcomes some of these problems, by providing a cargo carrier which is connected solely to the tongue of a standard trailer hitch. That carrier comprises a rack and a vertical member attached to one end of the rack, the vertical member having a threaded rod which is inserted through a corresponding hole in the trailer hitch. A pair of support brackets extend from the other end of the platform and are also affixed to the trailer hitch. These support brackets are attached to a pair of plates which engage and trap the trailer hitch tongue therebetween.
While the cargo rack of Tartaglia functions adequately for its intended purpose, its use incurs several drawbacks. The structure is relatively complex and takes some time to attach to the vehicle. Moreover, although not specifically disclosed in the patent, the cargo platform will necessarily be carried at some substantial height above the trailer hitch tongue. Presumably, this vertical displacement must be sufficient to permit the support brackets to provide some vertical support for the weight of the rack and the cargo carried thereon. In the embodiment shown in FIG. 2 of Tartaglia, the platform of the carrier is disclosed to be about level with the top of the trunk portion of the automobile on which the rack is carried. Cargo placed on the platform will necessarily sit outside a substantial portion of the slipstream created by the aerodynamic surfaces of the automobile body. Thus, the cargo rack will increase the wind resistance of the vehicle and decrease, albeit by a small amount, the fuel efficiency of the vehicle.
Of course, conventional trailers pulled by a trailer hitch suffer drawbacks as well. A complex support or spring system is often necessary to avoid transferring road shocks through the wheels to the cargo carried by the trailer. Because wheels are employed, the trailer is subject to the vagarities associated with a wheeled vehicle such as flat tires and the like. For these reasons, there is some not inconsiderable expense incurred in providing a cargo carrier with ground-engaging wheels.
The present invention overcomes these and other difficulties by providing a cargo carrier of simple and straightforward construction, yet which is easily attachable to the vehicle and provides isolation of the cargo from road shocks. The cargo carrier of the present invention is engageable with a conventional trailer hitch tongue. The tongue has a longitudinally extending tongue portion of somewhat uniform cross section. The cargo carrier comprises a platform and a means attached to the platform for insertably engaging the tongue portion. The engaging means is thus the sole means for transferring the weight of the carrier and its associated load to the vehicle. Preferably, the engaging means comprises a longitudinally extending engaging portion, which is hollow and shaped similarly to the tongue portion, but has a smaller cross section. The engaging portion is slidable into the tongue portion, and is affixed thereto by disposing a clevis pin in a set of registering holes in both the tongue and engaging portions. Attaching or removing the cargo carrier of the present invention to or from the vehicle on which it is carried is rapid, since the carrier does not connect to the vehicle body or the vehicle bumper. Also preferably, a weather storage unit is detachably carried on the platform portion of the carrier, and is large enough to receive one or more pieces of luggage or other cargo therein.
A better understanding of the present invention will be had upon reference to the following detailed description, when read in conjunction with the accompanying drawing, wherein like reference characters refer to like parts throughout the several ways, and in which:
FIG. 1 is a side view of the preferred embodiment of the present invention;
FIG. 2 is a perspective view of the preferred embodiment of the present invention;
FIG. 3 is a perspective view of another preferred embodiment of the present invention; and
FIG. 4 is a cross-sectional view taken along line 4--4 of FIG. 3, with parts removed for clarity.
With reference now to FIGS. 1 and 2, the cargo carrier 10 according to the present invention is thereshown detachably engaged with a vehicle 12. The vehicle 12 includes a trailer hitch 14, preferably a standard two inch square tube hitch. This standard hitch is conventionally adapted for the vertical insertion of a removable ball therein; however, this ball is preferably not present during use of the present invention. The trailer hitch 14 includes a tongue 16 having a longitudinally extending tongue portion 18. The tongue portion 18 is preferably of somewhat uniform cross section throughout its length.
The carrier 10 according to the present invention first comprises a cargo carrying platform 20. The platform 20 is approximately one and one-half inches thick, and approximately three and one-half feet wide by two and one-half feet long. It is preferably substantially horizontal and somewhat coplanar with the tongue portion 18. The platform 20 is preferably of an open bar construction, so as to provide substantial support for the cargo carried thereon, yet provide ample space for the passage of means (such as one or more straps 46) therethrough or therearound for attaching cargo to the platform.
The cargo carrier 10 of the present invention also comprises a means 24 for the detachable engagement of the carrier 10 with the tongue portion 18. The engagement means 24 is attached to the platform 20 at or near a platform end 26, the platform end 26 being the end proximal to the vehicle 12 and the trailer hitch 14. Preferably, engagement means 24 is attached to the platform 20 by one or more welds 23 and/or other fastening means (not shown) such as a plurality of bolts.
The engagement means 24 first comprises a trailer hitch engaging portion 28. The engaging portion 28 is preferably of a tubular construction, having a cross section of somewhat uniform shape throughout its length. Preferably also, the engaging portion 28 has a square cross section whose exterior dimensions are slightly smaller than the interior dimensions of the tongue portion 18.
The engagement means 24 also comprises a bar extending along the bottom of the platform beneath the longitudinal axis thereof. The platform 20 is attached to the bar 31 by welds 23. Although the bar 31 can be directly attached to the engaging portion 28, for example, by bolting, preferably an offset member 30 is disposed between the engaging portion 28 and the bar 31. The vertical distance that the offset member 30 displaces the platform 20 relative to the tongue portion 18 is small, as compared to the vertical distance between the tongue portion 18 and the continuation of the slip stream from the aerodynamic surfaces of the vehicle (measured at the end of the vehicle body), so that the platform 20 and any cargo carried thereon do not interfere substantially with the pattern of aerodynamic flow around the body and thereby increase the wind resistance of the vehicle. The offset member 30 is attached to the bar 31 by a pair of bolts 22, and welded to the engaging portion 28 by a weld 33.
Preferably, a support rod 60 is provided to give additional support for heavy loads and to reduce shock upon the carrier 10 from uneven roads and the like. The support rod 60 is attached to the underside of the hitch engaging portion 28, by means such as a weld 41 or bolts (not shown). The support rod 60 extends to a rearward end 62 of the bar 31 and is similarly attached thereto.
The tongue portion 18 is provided with one or more holes 32 which are adapted for registration with one or more holes provided in the engagement means 24, preferably in the engaging portion 28. Preferably, each of the tongue portion 18 and the engaging portion 28 have at least one pair of holes 32 and 34 disposed therein, respectively, one each of said holes disposed on either side of the tongue portion 18 and the engaging portion 28. The holes are dimensioned so as to permit the passage of a clevis pin 36 therethrough when the holes are in registration or alignment with one another. A lock 38 is preferably provided so as to prevent the inadvertent or unwanted removal of the clevis pin 36 from the holes 32 and 34. The holes 32 and 34, the clevis pin 36 and the lock 38 thereby comprise a means 39 for retaining the engagement portion 28 and the tongue portion 18 in engagement with one another, and thus the carrier 10 and the vehicle 12 in engagement with one another. Alternatively, the clevis pin 36 can be secured by a hitch pin clip (not shown).
The cargo carrier 10 also preferably comprises a cargo enclosure 40 attached to an upper surface 42 of the platform 20. The cargo enclosure 40 is preferably dimensioned so as to extend across substantially all of the platform 20. The cargo enclosure 40 can be of any desired height, but for efficient operation of the vehicle 12 it is preferred that the upper surface 43 of the cargo enclosure 40 be positioned and be of such a height so as to approximate a continuation of the aerodynamic surface 44 of the vehicle 12. Of course, it is preferable and convenient to make the cargo enclosure of two pieces, the pieces being engageable in a weatherproof fashion with one another. Also preferably, the cargo enclosure 40 is attached to the upper surface of the platform 20 by a means such as a set of straps 46 passing through or around the platform 20 and the cargo enclosure 40. Other attaching means, such as bolts or the like, can be employed as well. In a particularly preferred embodiment, a bottom 47 of the enclosure 40 is affixed to the platform 20 by means (not shown) such as a plurality of bolts, and the straps 46 omitted.
It should be evident from the preceding disclosure that, in order for the upper surface of the platform 42 to be near or within the slipstream of the aerodynamic surface 44 of the vehicle 12, the upper surface 42 of the platform 20 should be disposed between a tangential extension 48 of the aerodynamic surface 44 and a longitudinal axis 50 of the tongue portion 18. Such positioning results in a relatively low aerodynamic resistance, and thus in an increase in the fuel efficiency of the vehicle 12. Conventionally, the surface 44 and the axis 50 will be somewhat adjacent at the rear of the vehicle 12 and somewhat parallel to each other.
Although the upper surface of the platform 42 may be disposed beneath the longitudinal axis 50 of the tongue portion 18, and still be within the scope of the present invention, as a practical matter such a disposition is probably not preferred. The end of the carrier 10 distal to the vehicle 12 might touch the ground if the upper surface 42 of the platform 20 was so disposed, depending upon the weight of the cargo load, the flexibility of the carrier 10, and the road conditions upon which the vehicle 12 was driven.
Use of the cargo carrier 10 according to the present invention is straightforward. Starting from an engaged position, as shown in FIG. 1, the straps 46 are released and the cargo enclosure 40 is removed from the platform 20. The lock 38 is then unlocked, and the clevis pin 36 removed from the holes 32 and 34. The carrier 10 may then be easily slid from the tongue portion 18, because of the corresponding but slightly smaller cross section of the engaging portion 28. The entire disengagement process of the carrier 10 from the vehicle 12 can be performed in approximately one minute or less.
Attachment of the disengaged carrier 10 to the vehicle 12 is similarly straightforward. The engaging portion 28 is disposed parallel to and inserted into the tongue portion 18, the upper surface 42 of the platform 20 facing upwards. The carrier 10 is slid along the tongue portion 18 until the holes 32 in the tongue portion 18 are in registration with the holes 34 in the engagement portion 28. The clevis pin 36 is inserted into the holes 32 and 34, and locked therein by the lock 38. The cargo enclosure 40 is then attached to the platform 20 by use of the straps 46 and/or bolts (not shown). Of course, for convenience, it may be easier to first dispose the empty cargo enclosure 40 on the platform, then load the enclosure, and subsequently attach it to the platform 20 by the straps 46. Again, installation of the carrier 10 on the vehicle 12 generally takes approximately one minute or less.
Significant advantages arise from the cargo carrier construction according to the present invention. The cargo carrier 10 is substantially of one piece construction. It is connected solely to the tongue of a standard trailer hitch, and the engaging means serves as the sole means for transferring the weight of the carrier and its associated cargo to the vehicle. No support members or nuts or bolts are required to attach the carrier to the vehicle, other than the clevis pin previously described. Of course, other retaining means 39 can be provided, with the resulting carrier still remaining within the scope of the present invention.
Of course, the carrier 10 of the present invention can be made of larger or smaller dimensions than those previously described. Both the shape and size of the cargo carrying platform 20 and the cargo enclosure 40 can be varied according to the make or model of vehicle on which the carrier is to be employed, as well as according to the type of cargo (firewood, lumber, tools, merchandise, or the like) which will be carried.
Other advantages are evident as well. Use of the clevis pin 36 means that no tools are required for attaching the carrier to the vehicle. The carrier 10 does not need to connect to either the vehicle body or the vehicle bumper. It is employable with a standard trailer hitch or equalizer hitch. The cargo enclosure is preferably both weatherproof and lockable, so as to protect luggage, cargo and/or valuables. The lock 38 provides additional security to hinder the surreptitious removal of cargo from the carrier 10. Finally, the platform 20 and cargo enclosure 40 are preferably dimensioned large enough to carry packages, suitcases or merchandise of substantial size.
With particular reference now to FIGS. 3 and 4, another preferred embodiment for the present invention is thereshown, wherein the platform 20 comprises a rectangular frame 64, instead of the open construction described earlier. A plurality of selectively movable cargo supports 66 are insertably disposed between the sides of the frame 64. Cargo, such as a bicycle 68, rests thereon.
Preferably, the four sides of the frame 64 each comprise a 11/2 inch square tube, as do the supports 66. An angled plate 70 having an L-shaped cross section is affixed to each end 72 of each of the supports 66. The length of the supports 66 is selected so that the plates 70 slidably engage the interior walls 74 of the frame 64, when inserted therebetween. It is preferred that this engagement is frictionally strong enough so that the supports 66 will not bounce upwards from road shocks or slide transversely due to the weight of the cargo, yet be frictionally weak enough to permit the supports 66 to be manually shifted when desired. Except for these changes, this embodiment is similar to that described earlier, and is attached to the vehicle in the same way.
Having described my invention, however, many modifications thereto will become apparent to one skilled in the art to which it pertains without deviation from the spirit of the invention as defined by the scope of the appended claims.
Patent Citations
Referenced by
Legal Events
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4 Reviews
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The stuffing was easy to make and was very tasty; however, it was mushy and would not set. I would recommend draining the pineapple and also cut the amount of butter.
I've made this dish twice already. I was quite pleased when my MIL requested I bring it to her house the second time for Easter dinner. I add a little extra cinnamon into the bread mixture so that it spreads the flavor a little farther. Thanks for this keeper.
This recipe is definately a keeper. I halved the recipe and my DH ate almost half of it. He asked me to put the leftovers in the fridge so he could have it for bfast (it has eggs in it after all). I served it with chicken but would be much better served with pork in place of apple sauce. Very simple to make.
Made this for Easter. It was very easy to make, and it was quite tasty and sweet. My family loved it, said it will become an Easter traditon.

subset: commoncrawl


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Justin Bieber
Selena Gomez in Paige Premium
Selena Gomez spends some time hanging out with Justin Bieber. The two were seen spending the day together in Miami, Florida. Selena was later photographed sneaking into Justin's trailer. What do you think? Are they a couple or just friends?
Selena wore a loose fitting purple top, flats and a pair of skinny jeans. Her jeans are by Paige Premium. Later in the evening, Selena switched tops and paired her skinny jeans with a pair of gray boots and a white crop top. You can buy Paige Premium jeans at Paigeusa.com.
Justin Bieber in G Star Shirt
Justin Bieber posed for photos with his new book 'First Step 2 Forever' at Barnes & Noble in New York City a few days ago. I am beginning to wonder if Justin is sponsored by G Star because we always seem to see him in the brand, he doesn't really wear anything else. This time he was wearing one of their short sleeve denim shirts with dark jeans.
Have any of you younger readers/Justin fans bought his book or do you intend to? I personally think 16 is a little young to be writing an autobiography but maybe a lot has happened in his life and I know his girl fans would definitely want to know as much about him as possible. I saw him accepting his last award at the AMA's 2010 and he invited Usher on the stage to share it with him, I thought that was very kind of him.
Images courtesy of Wenn.com
Justin Bieber in G Star
Commemorating his massive 4 wins at the American Music Awards, Justin Bieber received a special surprise cake during his concert in Canada. Justin was joined onstage by his mother Pattie Mallette and other members of his family as his bodyguard Kenny Hamilton presented him with the yummy cake.
Justin was wearing his signature bright shirt, bright hi-tops and G Star jeans for the event. It cracks me up really, just last night my 4 year old was playing "Never Say Never" on YouTube over and over again and watching it and dancing. Both my kids can't get enough of Bieber!
Britney Spears in R13 Jeans
Britney Spears must love her R13 jeans! First, she was seen wearing them as she left a local bakery. She paired them with a loose white top and brown boots. The next day, she traded her white blouse for a floral patterned blouse, but kept the jeans and boots the same, as she swung by Starbucks.
Britney has been busy on Twitter! First she was tweeting Justin Bieber because he said he preferred Britney's perfume. She also sent out a few tweets asking for fans to vote for her in the upcoming People's Choice Awards. Who do you follow on Twitter? Make sure you're following us for great updates and giveaways, at @DenimBlog. You can buy R13 Jeans at Ssense.


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2014-15 Student handbook | 2015-16 School supply list | H.E.R.O. Newsletter | Free/reduced-price meal information | ABCDE calendar (PDF) | Home Access - 24/7 student data access
Mission Statement
In a nurturing environment, we guide and inspire children to achieve
their potential, develop meaningful relationships, and become lifelong
Since our opening in 1965,
the collaboration between families and staff is one of many things that
continues to make Royal Manor a welcoming and inviting learning
environment. On behalf of the entire Royal Manor ES community, welcome to
our home page and to the 2014-2015 school year.
This year's free or reduced price meal application is now available.
Learn More »
Do you know a student in need of a meal when the USDA-sponsored federal free and reduced-price school lunch program is unavailable?
The art of letter writing has not been lost on third grade students at Royal Manor Elementary!
Learn More »
The landscape will be changing at Royal Manor Elementary!


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The question of who would be the better Rupublician canidate is tough. The question of which would be a better President than Barry Obama is easy to answer. ANY OF THEM !!!! But must remember the "anybody but Bush" slogan helped get us in this mess. I hope we dont repeat the mistake of not really looking at the canidate a second time.


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Sheriff: Vehicles, bodies found in west Okla. lake could be decades-old cold cases
The remains were turned over to the medical examiner's office.
"We thought it was just going to be stolen vehicles and that's not what it turned out to be, obviously," Randolph said.
She said the Highway Patrol is hoping the discovery will offer some relief to families who may have gone decades wondering where a missing loved one was.
"We're hoping these individuals, that this is going to bring some sort of closure to some families out there who have been waiting to hear about missing people," she said. "If that's the case, then we're thrilled we were able to bring some sort of closure to those families."


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ROSE Blog Interviews: Con-Techie.com's Kendra "Admin" Schaefer
ROSE Blog: Rikki's Open Source Exchange
Con-Techie is a promising new site serving up geeky event news. Site admin Kendra "Admin" Schaefer shares her views on how the open source community should approach the growth of FOSS.
Q: Who are you?
A: My name is Kendra "Admin" Schaefer, abandoner of social networking accounts, surreptitious eater of last years' Halloween candy, FOSS graphic design advocate, and Ubuntu fan girl.
Q: What do you currently do in open source? What do you love about it?
A: Along with some extremely competent volunteers, I edit, administrate, and write for http://con-techie.com, a new open source conference directory and tech events blog.
Not to get too rah-rah-dead-Victorian-people on you, but when I think of open source, I think of Emma Goldman. She was feminist before they'd really sorted the word out, she had a lot to say about the social order of things, and she wrote an autobiography that makes me remember why I like reading in the first place.
She said, "If I can't dance, I don't want to be part of your revolution". So I think, if I can't dance, I don't wanna be part of your software. Open source lets me jitterbug.
Q: You're speaking to a group of women from other fields who are considering switching careers. Why should they consider moving into an open source-related career? What should they know about the open source environment to prepare them for the transition from a different field?
A: Well, I'll be honest. As a woman involved with open source, you're in a unique position. You don't have to be the first one to take the leap, there's already a support network – several support networks – of other smart, involved women there for you. You also get to be a bit of a novelty. And as a novelty, you place yourself in a position to pull other women up, and in, with you. As a novelty, you get to set an example. Open source is a career where women can still find plenty of uncharted territory.
On the flip side? "Here be dragons." And you are, as they say, particularly crunchy and good with ketchup.
Q: You're speaking to a group of high school students (male and female). Why should they consider exploring career options in open source?
A: Oh, man, convincing a classroom full of teenagers to do anything except squelch around in their own juices is beyond me. Tell them that shooting your co-workers with Nerf darts is part of the job description?
I don't think the challenge there is to get high school students to consider open source as a job description, because the ones that are already into tech are going to sidle that way if they're so inclined, but rather to let them know that it exists, and help them understand it, so when the non-geek kids hear the words "open source" somewhere down the line, they can go "oh, yeah, I know what that is." Defining and making the concept less oblique and lets open source companies exert a bit more gravitational pull on young talent. ...Muahaha.
Q: What question do you wish I'd asked? And how would you answer it?
A: I wish you'd asked how I think the open source community needs to approach the growth of FOSS, to which I would say, You're never going to get everyone in the world excited about, and willing to devote extra time to, your project. I mean, if I could only get six people to join my "I eat ice-cream in winter" Facebook group, no one's gonna be interested in your open source "telephony platform." Hah. Go-getters hate to hear this, but really, people are very attached to their apathy, and a healthy, popular, stable community has systems in place that allows for people to be as
'meh' as they need to be.
So it's up to the people with an inclination for activism, evangelism, and nerdiness to push open source platforms and software to the point that they're so works-out-of-the-box, so push-button, so commonplace and so viable that they're the easiest, most sensible thing to reach for. I don't
think we're 100% there yet. Some projects are, but not all. But we're on the way.
Issue 177/2015
Buy this issue as a PDF
NoScript Flaw
Mozilla's script blocker add-on could be putting malware sites on the whitelist.
RIP SSLv3
The Internet community officially banishes the notoriously unsafe Secure Sockets Layer protocol.
Mate 1.1 Arrives
Popular desktop environment continues the Gnome 2 legacy – with new support for the Gnome 3 toolkit.
US Government Requires HTTPS
The Obama White House has issued a memorandum telling all US government agencies they must use HTTPS for all websites and web communication.
Mozilla Signs Firefox Add-Ons
New program will dial up security for the Firefox browser.
Fedora 22 Arrives
Red Hat's community distro embraces the cloud.
Code.org and College Board Team Reach Out for Talented High School Coders
New partnership will bring more and better CS training to US schools
A Peek Inside TeslaCrypt Ransomware
Criminals offer online help over Tor network
Mumblehard Still Spams
Sophisticated malware is still present on Joomla and WordPress sites around the world.
Launchpad Gets Git
Future versions of Ubuntu's code service will support the popular Git version control system used with Linux and other open source projects.


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Apply online or on the go
within minutes
Receive an instant lending decision,** even
with less-than-perfect credit†
Get cash by the next business day*
It's amazing how many types of gems there are! From agate and emerald to jasper and spodumene, there's something for everybody. But did you know that if you own a gem, it probably came from Idaho? Our state is actually called the "Gem State" because nearly every known gemstone has been found here. But while they are beautiful to look at, they don't protect us Idahoans from emergency expenses. Trust us — we've thrown plenty of gemstones at those dreaded car repair bills! Luckily for us, a better alternative awaits at CashNetUSA!
As one of the leading payday loan providers online, CashNetUSA offers convenient Idaho payday loans to help you get through the tough times. Have you fallen behind on bills? Have you cracked your windshield and can't see while driving? Have you visited the emergency room recently and now face a hefty medical bill? If these situations sound similar, chances are you're in need of some quick cash. At CashNetUSA, just complete their easy 5-minute online application and if you're instantly approved,** you can get your money deposited directly into your checking account by the next business day!*
Save 25% on the initial loan fee of your first payday loan or receive a 25% rebate on the interest or fees of the first two payments of your first installment or installment-payday loan, respectively. Promo code not valid for the CashNetUSA line of credit product.+++
As an unemployed Idahoan, your first priority should be to find a job. It's in your best interest to start working and help alleviate some of the financial stress you're carrying around. But to answer your question, no, CashNetUSA will not give you a payday loan in Idaho if you are unemployed. Here are some statistics in Idaho that you should be aware of:


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Coachella 2014 Saturday Lineup: Skrillex, MGMT, Solange & More
Sunday, April 20, 2014 | 1 year ago
The party continued on Saturday with performances by Skrillex, Pet Shop Boys, Empire of the Sun, RL Grime, Mogwai, Pixies, Warpaint, MGMT, Solange, Lauryn Hill and Damien Marley w/ Nas and many more. All photos by Timothy Norris.
See also:
- Coachella 2014 Friday Lineup: Girl Talk, The Glitch Mob, Carnage & More
- Hipsters Taking Selfies at Coachella
As well as...
- Our complete Coachella coverage on the West Coast Sound music blog
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Click here to print the obituary below
David Anthony "Popcorn" Ourso
"We little knew that day, God was going to call your name. In life we loved you dearly, in death, we do the same. It broke our hearts to lose you; you did not go alone, for part of us went with you, the day God called you home. You left us beautiful memories, your love is still our guide and though we cannot see you, you are always at our side. Our family chain is broken, and nothing seems the same, but as God calls us one by one the chain will link again." A resident and native of Plaquemine, he passed away on Wednesday afternoon, Nov. 21, 2012. He was 56, and worked as a Master Carpenter. Visiting at St. John the Evangelist Catholic Church on Saturday, Nov. 24, 2012 from 8:30 a.m. until Mass of Christian Burial at 10 a.m. conducted by Rev. Cleo Milano. Interment in Grace Memorial Park. Survivors include his daughters, Jolynne Ourso, Sunni Ourso and Rachael Ourso; sons, David Ourso, Jr. and Michael Ourso and wife Megan; sisters, Neldres Voisin and husband George, Cookie Marionneaux and husband Chris, and Kim Ourso; brothers, John "Doonie" Ourso and wife Brenda, Stoney Michael Ourso, Freddie Ourso and Galen Ourso; 7 grandchildren, numerous nieces and nephews and special friends, Toni Jumonville and Benny Carringone. Preceded in death by his parents, Harvey & Mary Frances Ourso; brother, Rodney Ourso; and nephew, Kyle Ourso. He was an avid fisherman and a very gifted carpenter. Special thanks to Comfort Care Hospice. Arrangements by Wilbert Funeral Home, Plaquemine. Please share sympathies, condolences and memories online at
Funeral Home
Wilbert Funeral Home - Plaquemine
24120 Railroad Avenue
Plaquemine, LA 70764
Published in TheAdvocate.com from Nov. 23 to Nov. 24, 2012


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Treatment of Varicose Veins/Venous Insufficiency
Revision Date(s) 06/09/15; 05/12/15; 02/10/15; 06/09/14; 10/14/13; 06/14/13; 04/08/13
Greater or Lesser Saphenous Veins
Surgery (ligation and stripping), endovenous radiofrequency, laser ablation of greater or lesser saphenous veins or sclerotherapy (e.g. Varithena) may be considered medically necessary for symptomatic varicose veins/venous insufficiency when the following criteria have been met:
NOTE: If compression therapy is successful, it should be continued for as long as it is working. Failure of conservative therapy is defined as pain, swelling, itching, burning, or other symptoms associated with vein reflux, despite conservative therapy, severe enough to require daily pain medicines and causing inability to manage daily activities at home or at work.
Surgery, endovenous radiofrequency, laser ablation or sclerotherapy that does not meet the criteria described above is considered not medically necessary.
Treatment of the greater or lesser saphenous veins using any other techniques than noted above is considered investigational, including, but not limited to:
Accessory Saphenous Veins
Surgery (ligation and stripping), endovenous radiofrequency, laser ablation or sclerotherapy of the accessory saphenous veins may be considered medically necessary for symptomatic varicose veins/venous insufficiency when the following criteria have been met:
NOTE: If compression therapy is successful, it should be continued for as long as it is working. Failure of conservative therapy is defined as pain, swelling, itching, burning, or other symptoms associated with vein reflux, despite conservative therapy, severe enough to require daily pain medicines and causing inability to manage daily activities at home or at work.
Surgery, endovenous radiofrequency, laser ablation, or sclerotherapy of the accessory saphenous veins that does not meet the criteria described above is considered not medically necessary.
Treatment of the accessory saphenous veins using any other techniques than noted above is considered investigational, including, but not limited to:
Symptomatic Varicose Tributaries
The following treatments are considered medically necessary as a component of the treatment of symptomatic varicose tributaries when performed concurrently with or within 10 days of treatment (surgical, radiofrequency or laser) of the saphenous veins (none of these techniques has been shown to be superior to another):
When stab avulsion, hook phlebectomy, sclerotherapy, or transilluminated powered phlebectomy (TIPP) is requested more than 10 days following a prior surgical, radiofrequency or laser treatment, it may be considered medically necessary when there is documentation of one or more of the following indications:
NOTE: If compression therapy is successful, it should be continued for as long as it is working. Failure of conservative therapy is defined as pain, swelling, itching, burning, or other symptoms associated with vein reflux, despite conservative therapy, severe enough to require daily pain medicines and causing inability to manage daily activities at home or at work.
Treatment of symptomatic varicose tributaries when performed either at the same time or following prior treatment of saphenous veins using any other techniques than noted above is considered investigational, including, but not limited to:
Perforator Veins
Surgical ligation (including subfascial endoscopic perforator surgery) or endovenous radiofrequency or laser ablation of incompetent perforator veins may be considered medically necessary as a treatment of leg ulcers associated with chronic venous insufficiency when ALL of the following conditions have been met:
Ligation or ablation of incompetent perforator veins performed concurrently with superficial venous surgery is not medically necessary.
Treatment of incompetent perforator veins using any other techniques than noted above is considered investigational, including, but not limited to:
Treatment, by any method, of small telangiectasia such as spider veins (1mm or less), superficial reticular veins (1-2 mm), angiomata, and hemangiomata is considered cosmetic.
Documentation Requirements
Review of this technology requires the provider to specifically indicate:
• The CPT codes for the procedures being requested AND
• The name of the vein to be treated with each CPT code.
CPT Coding
Sclerotherapy: There is no specific CPT for microfoam sclerotherapy such as Varithena.
Providers might elect to use CPT codes describing sclerotherapy (36468-36471) or the unlisted vascular surgery procedure code 37799.
Stab avulsion or stab/hook/micro-phlebectomy may be billed using CPT codes 37765 or 37766
Transilluminated powered phlebectomy (TIPP): There is no specific CPT code for transilluminated powered phlebectomy. Unlisted vascular surgery procedure (37799) would apply to this service.
Greater/long saphenous veins – Superficial vein running the entire length of the leg and is generally 3 mm in its normal state. A typical GSV contains an average of 7 valves throughout its entire length, and it is the most common superficial vein to develop venous reflux.
Lesser/short saphenous veins – Superficial vein of the calf and is generally 2.5 mm in its normal state. The small saphenous vein originates at the back of the ankle near the outer malleous bone, and usually runs up the back of the lower leg to the popliteal vein behind the knee.
Accessory saphenous veins – Travel in parallel with the greater and lesser saphenous veins and are generally 2 - 2.5 mm in their normal state.
Tributary veins – Veins that empty into a larger vein
Perforator veins – Connect superficial veins to deep veins. They contain one-way valves to direct the blood from the superficial system to the deep system and are generally less than 3mm in their normal state.
Telangiectasia/Spider veins –Very small (≤1 mm in diameter) thread veins found commonly just under the surface of the skin, usually not distorting skin or surrounding tissues.
Moderate to severe reflux – In current practice, most vascular laboratories consider the presence of venous flow reversal for greater than 0.5 second with proximal compression, Valsalva maneuver, or distal compression and release to represent pathologic reflux.
Stab avulsion - This technique is also known as stab/hook phlebectomy. Stab avulsion results in removal of the varicose veins through incisions that are 2-3 mm in length. The veins are hooked with a tiny hook-like instrument and pulled out. The wounds are closed with tapes, not sutures, and the leg is wrapped in elastic compression support. Once healed, the incision sites are almost invisible.
A variety of treatment modalities are available to treat varicose veins/venous insufficiency, including surgical approaches, thermal ablation, and sclerotherapy. The application of each of these treatment options is influenced by the severity of the symptoms, type of vein, source of venous reflux, and the use of other (prior or concurrent) treatments.
The venous system of the lower extremities consists of the superficial veins (this includes the greater and lesser saphenous and accessory, or duplicate, veins that travel in parallel with the greater and lesser saphenous veins), the deep system (popliteal and femoral veins), and perforator veins that cross through the fascia and connect the deep and superficial systems. One-way valves are present within all veins to direct the return of blood up the lower limb. Since venous pressure in the deep system is generally greater than that of the superficial system, valve incompetence at any level may lead to backflow (venous reflux) with pooling of blood in superficial veins. Varicose veins with visible varicosities may be the only sign of venous reflux, although itching, heaviness, tension, and pain may also occur. Chronic venous insufficiency secondary to venous reflux can lead to thrombophlebitis, leg ulcerations, and hemorrhage.
CEAP Classification
The CEAP classification allows for a precise description of the type of venous disease being discussed and provides an orderly framework for decision making. It considers the clinical, etiologic, anatomic, and pathologic (CEAP) characteristics of venous insufficiency, ranging from class 0 (no visible sign of disease) to class 6 (active ulceration).
CEAP Classification of Chronic Venous Disease
Treatment of venous reflux/venous insufficiency is aimed at reducing abnormal pressure transmission from the deep to the superficial veins. Conservative medical treatment consists of elevation of the extremities, graded compression, and wound care when indicated. Conventional surgical treatment consists of identifying and correcting the site of reflux by ligation of the incompetent junction followed by stripping of the vein to redirect venous flow through veins with intact valves. While most venous reflux is secondary to incompetent valves at the saphenofemoral or saphenopopliteal junctions, reflux may also occur at incompetent valves in the perforator veins or in the deep venous system. The competence of any single valve is not static and may be pressure-dependent. For example, accessory saphenous veins may have independent saphenofemoral or saphenopopliteal junctions that become incompetent when the greater or lesser saphenous veins are eliminated and blood flow is diverted through the accessory veins.
Saphenous Veins and Tributaries
Saphenous veins include the greater and lesser saphenous and accessory saphenous veins that travel in parallel with the greater or lesser saphenous veins. Tributaries are veins that empty into a larger vein. Treatment of venous reflux typically includes the following:
The objective of sclerotherapy is to destroy the endothelium of the target vessel by injecting an irritant solution (either a detergent, osmotic solution, or chemical irritant), ultimately resulting in the occlusion of the vessel. The success of the treatment depends on accurate injection of the vessel, an adequate injectate volume and concentration of sclerosant, and compression. Historically, larger veins and very tortuous veins were not considered to be good candidates for sclerotherapy due to technical limitations. Technical improvements in sclerotherapy have included the routine use of Duplex ultrasound to target refluxing vessels, luminal compression of the vein with anesthetics, and a foam/sclerosant injectate in place of liquid sclerosant. Foam sclerosants are commonly produced by forcibly mixing a gas (e.g., air or carbon dioxide) with a liquid sclerosant (e.g., polidocanol or sodium tetradecyl sulfate). The foam is produced at the time of treatment.. Varithena (previously known as Varisolve, BTG PLC, London) is dispersed from a canister with a controlled density and more consistent bubble size.
Thermal Ablation
Radiofrequency (RFA) ablation is performed by means of a specially designed catheter inserted through a small incision in the distal medial thigh to within 1–2 cm of the saphenofemoral junction. The catheter is slowly withdrawn, closing the vein. Laser ablation is performed similarly; a laser fiber is introduced into the greater saphenous vein under ultrasound guidance; the laser is activated and slowly removed along the course of the saphenous vein. Cryoablation uses extreme cold to cause injury to the vessel. The objective of endovenous techniques is to cause injury to the vessel, causing retraction and subsequent fibrotic occlusion of the vein. Technical developments since thermal ablation procedures were initially introduced include the use of perivenous tumescent anesthesia, which allows successful treatment of veins larger than 12 mm in diameter and helps to protect adjacent tissue from thermal damage during treatment of the lesser saphenous vein.
Transilluminated Powered Phlebectomy (e.g. TRIVEX System)
Transilluminated powered phlebectomy (TIPP) is an alternative to stab avulsion or hook phlebectomy. This procedure uses 2 instruments: an illuminator which also provides irrigation, and a resector, which has an oscillating tip and can perform suction. Following removal of the saphenous vein, the illuminator is introduced via a small incision in the skin and tumescence solution (anesthetic and epinephrine) is infiltrated along the course of the varicosity. The resector is then inserted under the skin from the opposite direction, and the oscillating tip is placed directly beneath the illuminated veins to fragment and loosen the veins from the supporting tissue. Irrigation from the illuminator is used to clear the vein fragments and blood through aspiration and additional drainage holes. The illuminator and resector tips may then be repositioned, thereby reducing the number of incisions needed when compared with stab avulsion or hook phlebectomy. It has been proposed that TIPP might result in decreased operative time, decreased complications such as bruising, and faster recovery compared to the established procedures.
Treatment of Perforator Veins
Perforator veins cross through the fascia and connect the deep and superficial venous systems. Incompetent perforating veins were originally addressed with an open surgical procedure, called the Linton procedure, which involved a long medial calf incision to expose all posterior, medial, and paramedial perforators. While this procedure was associated with healing of ulcers, it was largely abandoned due to a high incidence of wound complications. The Linton procedure was subsequently modified by using a series of perpendicular skin flaps instead of a longitudinal skin flap to provide access to incompetent perforator veins in the lower part of the leg. The modified Linton procedure may be occasionally utilized for the closure of incompetent perforator veins that cannot be reached by less invasive procedures. Subfascial endoscopic perforator surgery (SEPS) is a less-invasive surgical procedure for treatment of incompetent perforators and has been reported since the mid-1980s. Guided by Duplex ultrasound scanning, small incisions are made in the skin, and the perforating veins are clipped or divided by endoscopic scissors. The operation can be performed as an outpatient procedure. Endovenous ablation of incompetent perforator veins with sclerotherapy and RF has also been reported.
Deep vein valve replacement is being investigated.
Outcomes of interest for venous interventions include healing and recurrence, recannulation of the vein, and neovascularization. Recannulation (recanalization) is the restoration of the lumen of a vein after it has been occluded; this occurs more frequently following treatment with endovenous techniques. Neovascularization is the proliferation of new blood vessels in tissue and occurs more frequently following vein stripping. Direct comparisons of durability for endovenous and surgical procedures are complicated by these different mechanisms of recurrence. Relevant safety outcomes include the incidence of paresthesia, thermal skin injury, thrombus formation, thrombophlebitis, wound infection, and transient neurologic effects.
Regulatory Status
The following devices have received specific U.S. Food and Drug Administration (FDA) marketing clearance for the endovenous treatment of superficial vein reflux:
Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage.
Treatment of Saphenous Reflux
Compression Therapy
A 2009 Cochrane review on compression for venous ulcers included a total of 39 randomized, controlled trials (RCTs), with 47 different comparisons. (1) Objective measures of healing were the time to complete healing, the proportion of ulcers healed within the trial period (typically 12 weeks), the change in ulcer size, and the rate of change in ulcer size. Evidence from 7 trials indicated that venous ulcers healed more rapidly with compression than without. Findings from 6 trials suggested that multi-component systems (bandages or stockings) were more effective than single-component compression. In addition, multi-component systems containing an elastic bandage appeared more effective than those composed mainly of inelastic constituents. Although this meta-analysis did not include time to healing, studies included in the review reported that the mean time to ulcer healing was approximately 2 months, while the median time to healing in other reports was 3 to 5 months.
A Cochrane review on compression stockings for the initial treatment of varicose veins in patients without venous ulceration was published in 2011. (2) Included in the review were 7 studies involving 356 participants with varicose veins without healed or active venous ulceration (CEAP [Clinical, Etiology, Anatomy, Pathophysiology] classification C2 to C4). Six of the studies compared different types or pressures of stockings. Subjectively, participants' symptoms improved, but results were not compared with a control arm. Due primarily to inadequate reporting, the methodologic quality of the included trials was unclear. Meta-analyses were not performed due to inadequate reporting and suspected heterogeneity. The authors concluded that 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 patients without venous ulceration, or whether any type of stocking is superior to any other type.
Ligation and Stripping
Systematic literature reviews published in 2008 indicate a similar healing rate of venous ulcers with superficial vein surgery and conservative compression treatments but a reduction in ulcer recurrence rate with surgery. (3, 4) In general, recurrence rates after ligation and stripping are estimated at around 20%. Jones and colleagues reported on the results of a study that randomized 100 patients with varicose veins to undergo either ligation alone or ligation in conjunction with stripping. (5) At 1 year, reflux was detected in 9% of patients, rising to 26% at 2 years. Rutgers and Kitslaar reported on the results of a trial that randomized 181 limbs to undergo either ligation and stripping or ligation combined with sclerotherapy. (6) At 2 years, Doppler ultrasound demonstrated reflux in approximately 10% of patients after ligation and stripping, increasing to 15% at 3 years.
Comparison of Endovenous Ablation and Sclerotherapy with Ligation and Stripping
An updated Cochrane review from 2014 compared endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus ligation/stripping for saphenous vein varices.8 Included in the review were 13 randomized studies with a combined total of 3081 patients. The overall quality of the evidence was moderate. There was no significant difference between sclerotherapy and surgery in the rate of recurrence as rated by clinicians (odds ratio [OR], 1.74; p=0.06) or for symptomatic recurrence (OR=1.28). For endovenous laser ablation (EVLA) versus surgery, there were no significant differences between the treatment groups for clinician noted or symptomatic recurrence, or for recanalization. Neovascularization and technical failure were reduced in the laser group (OR=0.05, p<0.001; and OR=0.29, p<0.001, respectively). For endovenous radiofrequency ablation (RFA) versus surgery, there were no significant differences between the groups in clinician noted recurrence, recanalization, neovascularization, or technical failure. The authors concluded that sclerotherapy, EVLA, and RFA are at least as effective as surgery in the treatment of great saphenous varicose veins.
In 2014, Brittenden et al. reported a multicenter randomized trial that compared foam sclerotherapy, EVLA, and surgical treatment in 798 patients. (9) The study was funded by U.K.'s Health Technology Assessment Programme of the National Institute for Health Research. Veins greater than 15 mm were excluded from the study. At the 6-week follow-up visit, patients who were assigned to treatment with foam or laser had the option of treatment with foam for any residual varicosities; this was performed in 38% of patients in the foam group and 31% of patients in the EVLA group. Six months after treatment, mean disease-specific quality of life was slightly worse after sclerotherapy than after surgery (p=0.006), and there were more residual varicose veins, although the differences were small. Disease-specific quality of life was similar for the laser and surgery groups. The frequency of procedural complications was similar for the foam sclerotherapy (6%) and surgery (7%) groups, but was lower in the laser group (1%). The rate of complications at 6 months (primarily lumpiness and skin staining), was highest for the sclerotherapy group.
Endovenous Radiofrequency Ablation
In 2008, Luebke and colleagues reported a meta-analysis of 8 studies that included a total of 224 patients who underwent RFA and 204 patients who underwent stripping. (8) There was no significant difference between RFA and surgery in immediate or complete greater saphenous vein occlusion, incomplete greater saphenous vein closure, freedom from reflux, recurrent varicose veins, recanalization, or neovascularization between the 2 treatments. There were significant reductions in tenderness and ecchymosis at 1 week and fewer hematomas at 72 hours, 1 week, and 3 weeks with RFA. Quality-of-life results, including return to normal activity and return to work, favored RF over surgery. The authors noted that rates of recanalization, retreatment, occlusion, and reflux may alter with longer follow-up and that further RCTs with longer follow-up are needed.
Long-term outcomes of endovenous RFA were reported from the Closure Study Group clinical registry in 2005. (9) Thirty-four centers (1,006 patients, 1,222 limbs) participated in the registry, with 12 centers contributing 5-year data (406 limbs). The registry included data on the treatment of 52 lesser saphenous veins and 16 accessory saphenous veins. Follow-up at 1 week showed a 97% anatomical success rate and a decrease in pain in 50% (from 85% to 30%) of patients. An additional 162 failures were identified over the 5 years of follow-up; 129 veins were found to have recanalization, and 33 limbs had reflux in the groin. Logistic regression analysis (risk factors of gender, age, body mass index [BMI], vein diameter, and catheter pullback speed) showed that BMI was associated with long-term failure. The rate of pull-back speed of the catheter during treatment was associated with failure to occlude or recanalization.
Endovenous Laser Ablation
The largest trial on EVLA is the 2012 RELACS study, which was a practical design that randomized 400 patients to EVLA performed by a surgeon at 1 site or to ligation and stripping performed by a different surgeon at a second location.12 At 2-year follow-up, there was no significant difference between the groups for clinically recurrent varicose veins, medical condition on the Homburg Varicose Vein Severity Score, or disease-related quality of life. Saphenofemoral reflux was detected by ultrasonography more frequently after endovenous laser treatment (EVLT) (17.8% vs 1.3%). This study will follow patients for 5 years. Another trial compared EVLA with ligation and stripping in 200 limbs (100 in each group).13 At 1-year follow-up, 98% of the limbs were reported to be free of symptoms. At 2-year follow-up, the EVLA group had 2 veins completely reopened and 5 partially reopened, which was significantly greater than in the ligation and stripping group. In the 2013 MAGNA trial, 223 consecutive patients (240 legs) with great saphenous vein reflux were randomized to EVLA, ligation and stripping, or foam sclerotherapy.14 At 1-year follow-up, the anatomic success rates were similar between EVLA and stripping (88.5% and 88.2%,respectively), which were superior to foam sclerotherapy (72.2%). Ten percent of the stripping group showed neovascularization. Health-related quality of life improved in all groups. The CEAP classification improved in all groups with no significant difference between the groups. Transient adverse events were reported in 11 patients after stripping, 7 after EVLA, and 5 after sclerotherapy.
Literature on isolated treatment of the anterior accessory saphenous vein is limited. In a 2009 study, outcomes from a cohort of 33 patients who underwent EVLA of the anterior accessory saphenous vein were compared with 33 matched controls undergoing EVLA of the greater saphenous vein.15 In 21 of the patients (64%) in the accessory saphenous vein group, there had been no previous treatment of the greater saphenous vein. At 12-month follow-up, there was no evidence of reflux in these patients, and the treated accessory saphenous vein was not visible with ultrasound. The Aberdeen Varicose Vein Symptom Severity Score had improved in both groups, with no significant difference between the 2 groups. Patient satisfaction scores were also similar.
Endovenous Cryoablation
Klem and colleagues reported a randomized trial in 2009 that found endovenous cryoablation (n=249) to be inferior to conventional stripping (n=245) for treating patients with symptomatic varicose veins. (14) The percentage of patients with greater saphenous vein remaining was 44% in the endovenous cryoablation group and 15% in the conventional stripping group. The Aberdeen Varicose Vein Questionnaire also showed better results for conventional stripping (score of 11.7) in comparison with cryoablation (score of 8.0). There were no differences between the groups in Short-Form-36 (SF-36) subscores, and neural damage was the same (12%) in both groups.
Disselhoff and colleagues reported 2 and 5 year outcomes from a randomized trial that compared cryostripping with EVLA. (15, 16) Included were 120 patients with symptomatic uncomplicated varicose veins (CEAP C2) with saphenofemoral incompetence and greater saphenous vein reflux. At 10 days after treatment, EVLA had better results than cryostripping with respect to pain score over the first 10 days (2.9 vs. 4.4), resumption of normal activity (75% vs. 45%) and induration (15% vs. 52%). At 2 year follow-up, freedom from recurrent incompetence was observed in 77% of patients after EVLA and 66% of patients after cryostripping (not significantly different). At 5 years, 36.7% of patients were lost to follow-up; freedom from incompetence and neovascularization was found in 62% of patients treated with EVLA and 51% of patients treated with cryostripping (not significantly different). Neovascularization was more common after cryostripping, but incompetent tributaries were more common after EVLA. There was no significant difference between groups in the Venous Clinical Severity Score or Aberdeen Varicose Vein Severity Score at either 2 or 5 years.
In the 2013 MAGNA trial (previously described), 223 consecutive patients (240 legs) with great saphenous vein reflux were randomized to EVLA, ligation and stripping, or physician compounded foam sclerotherapy (1 cc aethoxysclerol 3%: 3 cc air). (14) At 1-year follow-up, the anatomic success rate of foam sclerotherapy (72.2%) was inferior to both EVLA and stripping (88.5% and 88.2%, respectively). Twentyone patients in the sclerotherapy group had partial occlusion with reflux, though the clinical complaint was completely relieved. A 2012 study was a noninferiority trial of foam sclerotherapy versus ligation and stripping in 430 patients. (16) Analysis was per protocol. Forty patients (17%) had repeat sclerotherapy. At 2 years, the probability of clinical recurrence was similar in the 2 groups (11.3% sclerotherapy vs. 9.0% ligation and stripping), although reflux was significantly more frequent in the sclerotherapy group (35% vs. 21%). Thrombophlebitis occurred in 7.4% of patients after sclerotherapy. There were 2 serious adverse events in the sclerotherapy group (deep venous thrombosis and pulmonary emboli) that occurred within 1 week of treatment.
In 2013, Varithena™ microfoam was approved under a new drug application for the treatment of varicose veins. Efficacy data were from 2 randomized, blinded, multicenter studies. (17) One evaluated Varithena™ at 0.5%, 1.0%, and 2.0% polidocanol and the second evaluated Varithena™ at 0.5% and 1.0% polidocanol compared with endovenous placebo or a subtherapeutic dose of polidocanol foam. The primary end point was improvement in symptoms at week 8, as measured by the Varicose Vein Symptoms Questionnaire. The improvement in symptoms was greater in the pooled Varithena™ treatment group (p<0.001) and in each of the individual dose-concentration groups compared with vehicle alone. Secondary and tertiary end points (appearance, duplex ultrasound response, quality of life) were also significantly better for the Varithena™ groups compared with controls.
The second study, called VANISH-2, was published in 2014. (18) At the 8-week assessment, there was elimination of reflux and/or occlusion of the previously incompetent vein in 85.6% of the combined 0.5% and 1.0% groups, 59.6% of patients in the 0.125% group, and 1.8% of the placebo group. Analysis of data from both studies showed a dose response from 0.5% to 2.0% for improvement in appearance and from 0.5% to 1.0% for Duplex responders. The 1.0% dose of Varithena™ was selected for the FDA approval. Safety analysis found deep vein thrombosis detected by ultrasound in 2.8% of Varithena™-treated patients with 1% of patients having proximal symptomatic thrombi; these were treated with anticoagulants. There was no signal of an increase in neurological adverse events, and there were no adverse cardiac or cardiopulmonary effects following treatment with Varithena™ injectable foam. Rates of occlusion with Varithena™ are similar to those reported for EVLA or stripping. A randomized trial comparing EVLA and stripping with this new preparation of foam sclerotherapy is needed to evaluate its comparative effectiveness. Evaluation out to 5 years is continuing.
Endovenous Cryoablation
Klem et al. reported a randomized trial in 2009 that found endovenous cryoablation (n=249) to be inferior to conventional stripping (n=245) for treating patients with symptomatic varicose veins. (24) The percentage of patients with greater saphenous vein remaining was 44% in the endovenous cryoablation group and 15% in the conventional stripping group. The Aberdeen Varicose Vein Questionnaire also showed better results for conventional stripping (score, 11.7) in comparison with cryoablation (score, 8.0). There were no differences between the groups in SF-36 subscores, and neural damage was the same (12%) in both groups.
Disselhoff et al. reported 2 and 5 year outcomes from a randomized trial that compared cryostripping with EVLA. (25, 26) Included were 120 patients with symptomatic uncomplicated varicose veins (CEAP C2) with saphenofemoral incompetence and greater saphenous vein reflux. At 10 days after treatment, EVLA had better results than cryostripping with respect to pain score over the first 10 days (2.9 vs. 4.4), resumption of normal activity (75% vs 45%) and induration (15% vs 52%). At 2-year follow-up, freedom from recurrent incompetence was observed in 77% of patients after EVLA and 66% of patients after cryostripping (not significantly different). At 5 years, 36.7% of patients were lost to follow-up; freedom from incompetence and neovascularization was found in 62% of patients treated with EVLA and 51% of patients treated with cryostripping (not significantly different). Neovascularization was more common after cryostripping, but incompetent tributaries were more common after EVLA. There was no significant difference between groups in the Venous Clinical Severity Score or Aberdeen Varicose Vein Severity Score at either 2 or 5 years.
Other Treatments
Both steam injection and microwave ablation for endovenous treatment of varicose veins were reported outside of the United States.27-29 These procedures have not been approved or cleared for marketing by FDA.
Section Summary
There are a number of large randomized trials on endovenous ablation of the saphenous veins. Comparison with ligation and stripping at 2-year follow-up supports use of both RFA and EVLA. Evidence suggests that ligation and stripping may lead to neovascularization, while thermal ablation may lead to recanalization. Controlled studies with longer follow-up are needed to determine the long-term efficacy of these treatments with greater certainty. Two RCTs suggest that cryotherapy is not as effective as available alternatives. For physician-compounded sclerotherapy, there is high variability in success rates of the procedure and reports of serious adverse events. Rates of occlusion with the FDA-approved microfoam sclerotherapy are similar to those reported for EVLA or stripping.
Treatment of Tributary Varicosities
Sclerotherapy and Phlebectomy
Early studies established ligation and stripping as the gold standard for the treatment of saphenofemoral incompetence based on improved long-term recurrence rates, with sclerotherapy used primarily as an adjunct to treat varicose tributaries. A 2006 Cochrane Review, based primarily on RCTs from the 1980s, concluded that, "The evidence supports the current place of sclerotherapy in modern clinical practice, which is usually limited to treatment of recurrent varicose veins following surgery and thread veins." (27) Sclerotherapy and phlebectomy are considered appropriate in the absence of reflux of the saphenous system, e.g., post- or adjunctive treatment to other procedures such as surgery. In 2014, El-Sheikha et al. reported a small randomized trial of concomitant or sequential (if needed) phlebectomy following EVLA for varicose veins.32 Quality of life and clinical severity scores were similar between the groups by 1 year, with 16 of 24 patients (67%) in the sequential phlebectomy group receiving a secondary intervention.
A small proportion of patients may present with tributary varicosities in the absence of saphenous reflux. For example, of 1,009 patients recruited for an RCT, 64 patients were found to have minor varicose veins without reflux, 34 of whom agreed to be randomized to sclerotherapy or conservative treatment. (28) At baseline, 92% had symptoms of heaviness, 69% had cosmetic concerns, 53% reported itching, and 30% reported relief of symptoms through the use of compression hosiery. At 1 year follow-up, there was an improvement in clinicians' assessment of the anatomical extent of varicose veins, with 85% of patients in the sclerotherapy group improved compared to 29% of patients in the conservative-therapy group. Symptoms of aching were better or eliminated in 69% of the sclerotherapy group and 28% of the group treated with conservative therapy. Cosmetic concerns were improved in 85% of the sclerotherapy patients and 14% of controls.
The bulk of the literature discussing the role of ultrasound guidance refers to sclerotherapy of the saphenous vein, as opposed to the varicose tributaries. In 2012, Yamaki et al. reported a prospective randomized controlled trial that compared visual foam sclerotherapy vs. ultrasound-guided foam sclerotherapy of the greater saphenous vein together with visual foam sclerotherapy for varicose tributary veins. (29) A total of 51 limbs in 48 patients were treated with ultrasound-guided foam sclerotherapy plus visual foam sclerotherapy of the varicose tributaries, and 52 limbs in 49 patients were treated with foam sclerotherapy alone. At 6-month follow-up, complete occlusion was found in 23 limbs (45.1%) treated with ultrasound-guided and visual-guided foam sclerotherapy and in 22 limbs (42.3%) treated with visual sclerotherapy alone. Reflux was absent in 30 limbs (58.8%) treated with ultrasound and visual guidance and in 37 (71.2%) treated with visual guidance alone (not significantly different). The authors note that for the treatment of tributary veins in clinical practice, most patients receive direct injection of foam without ultrasound guidance.
Transilluminated Powered Phlebectomy (TIPP)
A 2008 meta-analysis included 5 studies that compared TIPP with conventional surgery. (30) Results showed a significant advantage of TIPP over the conventional treatment for number of incisions, mean cosmetic score, and duration of the procedure. However, TIPP also increased the incidence of hematoma and resulted in worse mean pain scores. Included in the meta-analysis was a randomized clinical trial by Chetter et al. that compared TIPP (n=29) with a multiple stab incision procedure (n=33). (31) A single surgeon performed all but 2 of the procedures, and there was no difference in operating time. Patients treated with TIPP had an average of 5 incisions, compared with 20 for the multiple stab procedure. However, blinded evaluation revealed that bruising or discoloration was higher for the TIPP group at both 1 and 6 weeks after surgery. At 6 weeks after surgery, patients in the TIPP group showed no improvement in pain (-2 points on the Burford pain scale), while patients in the multiple stab incision group had a significant improvement in pain score compared with presurgical baseline (-20 points). At 6 weeks after surgery, quality-of-life measures had improved in the multiple-stab incision group but not in the TIPP group. Thus, although TIPP had the advantage of fewer surgical incisions, in this single-center study, it was associated with a more prolonged recovery due to more extensive bruising, prolonged pain, and reduced early postoperative quality of life. The current literature does not show an advantage of TIPP over conventional treatment.
Section Summary
Evidence indicates that both sclerotherapy and TIPP are as effective as stab phlebectomy in eliminating varicose tributaries. However, there is limited evidence that TIPP is associated with more pain, bruising, discoloration, and a longer recovery.
Treatment of Perforator Reflux
A systematic literature review published in 2008 indicates insufficient evidence for the role of incompetent perforator vein surgery. (4) These conclusions were based on 4 RCTs published since 2000 that compared superficial vein surgery with conservative therapy in advanced chronic venous insufficiency (CEAP category C5/6). The 4 trials included 2 level I (large subject population) and 2 level II (small subject population) studies. Two of the trials combined surgical treatment of the incompetent perforator veins with concurrent or prior treatment of the superficial saphenous veins; the other 2 treated the greater saphenous vein alone. The 2 randomized studies in which the greater saphenous vein alone was treated (including the ESCHAR trial) showed a significant reduction in ulcer recurrence in comparison with conservative therapy. (32, 33) A 2011 community hospital-based multicenter, double-blind, randomized trial found no clinical benefit (self-reported symptoms) from adding subfascial endoscopic perforator surgery (SEPS) to saphenous surgery in 75 patients with varicose ulcers (CEAP C5 or C6) and incompetent perforators. (34)
Treatment of the great saphenous vein alone has been reported to improve perforator function. For example, one study showed that reversal of perforator vein incompetence (41% of 68 previously incompetent perforators) was more common than new perforator vein incompetence (22% of 183 previously competent perforators) following superficial vein surgery. (35) O'Donnell discusses additional (lower quality) evidence to suggest deep venous valvular involvement rather than incompetent perforators in venous insufficiency. (4) Thus, although incompetence of perforator veins is frequently cited as an important etiologic factor in the pathogenesis of venous ulcer, current evidence does not support the routine ligation or ablation of perforator veins.
Subfascial Endoscopic Perforator Surgery (SEPS)
In 2004, Tenbrook and colleagues published a review of the literature of SEPS, which included 19 case series and one randomized trial. (36) In total, the reviewed studies included 1,031 patients with 1,140 treated limbs. The authors concluded that SEPS was associated with excellent results in terms of ulcer healing and prevention of recurrence. However, the authors also noted that randomized trials are required to define the relative contributions of compression therapy, superficial venous surgery, and SEPS in the management of severe venous disease. A 2009 meta-analysis of SEPS for chronic venous insufficiency concludes that "Its [SEPS] use should not be employed routinely and could only be justified in patients with persistent ulceration thought to be of venous origin, and in whom any superficial reflux has already been ablated and post-thrombotic changes excluded." (37) The authors also state that "introduction of less invasive techniques for perforator vein ablation, such as ultrasound-guided sclerotherapy or radiofrequency ablation, may diminish the role of SEPS in the future."
Other Treatments
A 2008 review of procedures for management of varicose veins recommends duplex-guided foam sclerotherapy, microincision phlebectomy, or thermal ablation using a new short RF catheter for the treatment of symptomatic residual perforator vein incompetence. (38) Ablation of incompetent perforator veins with laser or RFA had been shown to be technically feasible, although no studies had been identified that showed an improvement in clinical outcomes (e.g., ulcer healing or recurrence). (18-20, 26) The 2011 literature update identified one study of EVLA for perforating veins in 33 patients with a CEAP classification of 4 (skin changes), 5 (healed ulcer), or 6 (active ulcer). (39) All incompetent saphenous trunks were treated simultaneously (63% of limbs). At 3-month follow-up, occlusion was achieved in 78% of the perforating veins. Five patients (15%) had active ulcers at baseline; 4 of the 5 ulcers had healed by 6 weeks after EVLA. Evidence regarding the treatment of perforator veins with ultrasound-guided sclerotherapy is limited, and there is a risk of deep venous occlusion. (25)
Although randomized, controlled trials with longer follow-up are needed to evaluate long-term durability, and repeat treatments may be required, evidence indicates that endovenous treatment of saphenous veins with radiofrequency or laser ablation improves short-term clinical outcomes (e.g., pain and return to work) in comparison with surgery. Ultrasound-guided foam sclerotherapy leads to success rates that approach that of surgery. There are no trials comparing the recently FDA-approved microfoam sclerotherapy with other treatments of varicose veins, although studies comparing microfoam sclerotherpay to placebo showed statistically significant success in the elimination of reflux and/or occlusion of previously incompetent veinsResults from a recent randomized, controlled trial of cryoablation indicate that this therapy is inferior to conventional stripping.
The literature indicates that sclerotherapy of tributaries following occlusion of the saphenofemoral or saphenopopliteal junction and saphenous veins may be considered medically necessary. Evidence is insufficient to evaluate the health benefit of sclerotherapy as a sole treatment of varicose tributaries without prior or concurrent treatment of the saphenous veins. No studies have been identified that compare radiofrequency or laser ablation of tributary veins with standard procedures (microphlebectomy and/or sclerotherapy). Transilluminated powered phlebectomy is effective at removing varicosities; outcomes are comparable to available alternatives such as stab avulsion and hook phlebectomy.
The literature indicates that the routine ligation/ablation of incompetent perforator veins is not medically necessary for the treatment of varicose veins/venous insufficiency at the time of superficial vein procedures. However, when combined superficial vein procedures and compression therapy have failed to improve symptoms (i.e., ulcers), treatment of perforator vein reflux may be as beneficial as any alternative (e.g., deep vein valve replacement). Therefore, treatment of incompetent perforator veins may be considered medically necessary in this specific situation.
Comparative studies are needed to determine the most effective method of ligating/ablating incompetent perforator veins. SEPS has been shown to be as effective as the Linton procedure with a reduction in adverse events. Although only one case series has been identified showing an improvement in health outcomes, endovenous ablation with specialized laser or radiofrequency probes has been shown to effectively ablate incompetent perforator veins with a potential decrease in morbidity in comparison with surgical interventions. For sclerotherapy, concerns have been raised about the risk of deep vein occlusion, and evidence is currently insufficient to evaluate the safety or efficacy of this treatment for incompetent perforator veins.
Practice Guidelines and Position Statements
The Society for Vascular Surgery and the American Venous Forum published clinical practice guidelines in 2011. (40) The recommendations are rated as strong=1 or weak=2, based on a level of evidence that is either high quality=A, moderate quality=B, or low quality=C, and include the following:
In 2009, the American College of Radiology published appropriateness criteria for the treatment of lower-extremity venous insufficiency. (41) The following is a summary of treatment options:
In 2003, the Society of Interventional Radiography (SIR) published a position statement (42) that considered endovenous ablation therapy, using either laser or radiofrequency devices under imaging guidance and monitoring, an effective treatment of extremity venous reflux and varicose veins under the following conditions:
In a joint statement published in 2007, the American Venous Forum and SIR recommended reporting standards for endovenous ablation for the treatment of venous insufficiency. (43) The document recommended that reporting in clinical studies should include the symptoms of venous disease, history of disease and prior treatment, the presence of major comorbidities, and any exclusion criteria. It was noted that potential candidates for endovenous ablation may include patients with reflux in an incompetent greater saphenous vein or smaller saphenous vein or in a major tributary branch of the greater or smaller saphenous veins such as the anterior thigh circumflex vein, posterior thigh circumflex vein, or anterior accessory greater saphenous vein. The presence of reflux in these veins is important to document using duplex ultrasound imaging, and the ultrasound criteria used to define reflux should be indicated. It was also stated that in current practice, most vascular laboratories consider the presence of venous flow reversal for greater than 0.5 to 1.0 second with proximal compression, Valsalva maneuver, or distal compression and release to represent pathologic reflux.
In 2003 and 2004, the U.K.'s National Institute for Health and Clinical Excellence (NICE) published guidance on radiofrequency ablation of varicose veins and on endovenous laser treatment of the long saphenous vein. (44, 45) NICE concluded that the evidence on the safety and efficacy appeared adequate to support the use of these procedures provided that the normal arrangements were in place for consent, audit, and clinical governance. The evidence on efficacy at this time was limited to case series with limited follow-up. Clinicians were encouraged to collect longer-term follow up data.
NICE issued updated guidance on ultrasound-guided foam sclerotherapy for varicose veins in 2013. (52)
The guidance states that:
"1.1 Current evidence on the efficacy of ultrasound-guided foam sclerotherapy for varicose veins is adequate. The evidence on safety is adequate, and provided that patients are warned of the small but significant risks of foam embolization (see section 1.2), this procedure may be used with normal arrangements for clinical governance, consent and audit.
1.2 During the consent process, clinicians should inform patients that there are reports of temporary chest tightness, dry cough, headaches and visual disturbance, and rare but significant complications including myocardial infarction, seizures, transient ischaemic attacks and stroke."
NICE issued guidance on endovenous mechanochemical ablation in 2013, concluding that current evidence on the safety and efficacy of endovenous mechanochemical ablation for varicose veins is inadequate in quantity and quality. (53) Therefore this procedure should only be used with special arrangements for clinical governance, consent, and audit or research.
In 2013, NICE published practice guideline on the diagnosis and management of varicose veins in the leg. (54) NICE recommends a study of the clinical and cost effectiveness of
U.S. Preventive Services Task Force Recommendations
Not applicable.
Medicare National Coverage
There is no national coverage determination (NCD). In the absence of an NCD, coverage decisions are left to the discretion of local Medicare carriers.
Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk
Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); face
Injection of sclerosing solution; single vein
Injection of sclerosing solution; multiple veins, same leg
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)
Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS)
Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions
Ligation, division, and stripping, short saphenous vein
Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below
Ligation and division and complete stripping of long and short saphenous veins with radical excision of ulcer and skin graft and/or interruption of communicating veins of lower leg, with excision of deep fascia
Ligation of perforator veins, subfascial, radical (Linton type) including skin graft, when performed, open, 1 leg
Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg
Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions
Stab phlebectomy of varicose veins, 1 extremity; more than 20 stab incisions
Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure)
Ligation, division, and/or excision of varicose vein cluster(s), one leg
Unlisted procedure, vascular surgery
Replace policy. Formatting changed to now organize procedures by type of vein. Policy statement extensively revised with additional medically necessary criteria for each procedure. Sclerotherapy now considered medically necessary only for accessory and tributary veins. Policy on hold for provider notification; the effective date is May 19, 2013.
Policy statement clarification. In criteria for sclerotherapy of accessory saphenous veins when not done concurrently with other listed treatments, the moderate to severe saphenous reflux criterion has been removed. To clarify the definition of "symptomatic" for treatment of tributaries not done concurrently with other listed treatments, specific criteria added for stab avulsion, hook phlebectomy, sclerotherapy or transilluminated powered phlebectomy treatment of tributaries. Tributary criterion for moderate to severe saphenous reflux, when not done concurrently with other listed treatments, has been removed.
Minor clarification. Hook phlebectomy clarified to indicate that it is also known as stab phlebectomy or micro-phlebectomy.
Replace policy. CPT codes for sclerotherapy (36468, 36469, 36470, 36471), TIPP (37765 or 37766, stab avulsion (37765, or 37799), etc. added to Policy Guidelines section.
Update Related Policies. Add 10.01.514.
Interim update. Criteria for vein size removed from policy statement. Minor edit to change definition of "moderate to severe reflux" to greater than 0.5 second. Coding update: ICD-9 and ICD-10 diagnosis and procedure codes removed – these are not utilized for adjudication.
Annual Review. Policy updated with literature review through September 23, 2014; reference 8-9, 18, 24 33 added and some references removed; policy statement revised to allow sclerotherapy as medically necessary when criteria are met. Information added regarding FDA approval of Varithena sclerotherapy. Documentation requirements added to Policy Guidelines.
Interim Update. Policy statement clarified: Treatment of tributaries by sclerotherapy, stab avulsion, stab/hook phlebectomy or transilluminated powered phlebectomy may now be considered medically necessary up to 10 days after saphenous veins have been treated. Definition of moderate to severe saphenous reflux and abbreviation "TIPP" added to the policy statement.
Interim Update. Policy statement clarified: TRIVEX listed as an example of TIPP. Exercises and pain relievers removed from conservative management requirement. TRIVEX manufacturer website added to Reference section. CPT codes 76942, 93970-71 and HCPCS code S2202 removed; these are not reviewed.
Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).


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RELATED: Transit partners to offer first-, last-mile optionsA $350,000 grant from the Virginia Department of Transportation, as well as subsidies from UVa's department of parking and transportation and membership fees, will fund the program. UVa officials selected New York City-based startup Social Bicycles for the project. The bikes themselves will have systems to gather data on where and when the bicycles are being used, according to the report.
For the full story, click here.
The new zero-emission electric double-deck buses manufactured by BYD will enter service beginning in October.
Tier 4 locomotives are expected to reduce particulate matter and nitrogen oxide emissions by more than 85% compared to current Tier 0 locomotive engines.
As part of this $50 million program, a new 49,000 square-foot high-bay maintenance building, a 12,000 square-foot operations and administration building, and a two-bay bus wash building were added to the existing facility complex.
The new product would allow universities, transit agencies and for-hire transportation companies that use small shuttle buses to easily cut fuel costs while supporting sustainability efforts.
Additional records include gradeability, weight and acceleration. While conventional diesel buses average 3.86 MPG, the Proterra Catalyst achieved the best efficiency rating ever for a 40-foot transit bus at 22 MPGe.
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Join us as we fight to return this country back to fiscal responsibility, smaller government, and encourage the free market system.
Bill Miller - Events/Legislation
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Pat Hartnagle - Legislation
Stan Mueller - Legislation
Jan Woodruff - Treasurer
I want to see that DNR Officer that shot the pet pig fired. Lets get together and call for his job.
Posted by David Arthur Czerney on April 4, 2015 at 6:02pm — 2 Comments
If You Could, Would You FIRE the IRS?
A Summary of the Call for a New Fair Tax Amendment
The new Article V FairTax Resolution, proposed by state legislatures under a provision of the U.S. Constitution, is a proposed addition to the Constitution that would replace our current unworkable federal tax code with a simple and FAIR consumption tax. The…Continue
Posted by Tom Llewellyn on March 17, 2015 at 8:50pm — 1 Comment
Can someone tell me if this lady is someone we would like in this office?
If not, who would you suggest supporting?
Posted by Dan McGillivray on January 15, 2015 at 8:23pm — 2 Comments
If you can attend, would like to carpool, are available to drive, etc. please reply here. That way people can see if they can catch a ride, can take some passengers, and hopefully we can get a group of 20 or more headed to Lansing next week. This is what we have been wanting and waiting for. Let's not disappoint those who have worked so hard to get this hearing. Thanks as always for your support.
Posted by Tammy Hyatt on November 26, 2014 at 10:22pm — 2 Comments
Is everyone done dancing in the streets over the GOP "wave" that happened across this great nation on Tuesday evening? (I believe the career politicians [especially those with shall we say "loftier"…Continue
Started by Kyle Jaskulka. Last reply by Tammy Hyatt Nov 26, 2014.
Excellent analogy.I could not get excited about what happened on November 4, because nothing seems to ever change. Please keep digging, Tammy, you are our voice of truth.Thank you.Jo LongendykeContinue
Started by Jo A Longendyke. Last reply by Tammy Hyatt Nov 26, 2014.
November 12, 2014 Where in this once wonderful experiment of a self-governed Republic did 'We The People' lose control over our own destinies and, in the process, the power to control…Continue
Started by Kyle Jaskulka Nov 22, 2014.
If you were president of the National Tea Party and could send an email "action" list to millions of conservative patriots - what would it say? What action would you take this week considering events…Continue
Started by Tammy Hyatt. Last reply by Gary Michael Loftis Jul 7, 2014.
Created by Jamie Hazen Nov 7, 2009 at 2:47pm. Last updated by Dan McGillivray Aug 2, 2010.
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Cinderella Storybook (Listen and Read)
The traditional tale of Cinderella, retold with a simple text, colourful illustrations and full sound support.
This is a 'Listen and Read' book, which has short, simple text and audio support. Turn the pages using the arrows and click the loudspeaker to hear the story read out.
This activity is featured in
BOOKSHELF - Traditional Tales
The full set of TES iboard+ Traditional Tales storybooks - listen, read and share! 'Listen and Read' books are simply written, with shorter text, and contain a 'read-it-to-me' audio button. 'Reading Level A' books are longer texts for sharing with the whole class or for more independent readers (and also have optional audio support). For a bookshelf collection of 'stories with familiar settings' click here
NARRATIVE - Giants and Fairies (4-7)
NOTE: A fuller version of this pack exists in the 7-9 section. This KS1 version will be taken off the site by the end of Summer Term 2015. We will replace it with a new Fairy Tale pack. This pack explores the 'fairy' tales of Cinderella and Jack and the Beanstalk, looking at characters and structure. Using the visual stimulus of our giant and fairy images, pupils plan and write their own tales. Alternatively, pupils can write an extra chapter for the story of Jack and the Beanstalk or a newspaper report.
NARRATIVE - Giants and Fairies (7-9)
What makes a good 'fairy' tale? This unit explores story heroes and villains, using the examples of fairies and giants. Pupils compare two 'fairy' tales: Cinderella and Jack and the Beanstalk, noting features of the genre. They then write their own tale, using images of giants and fairies as a visual stimulus. To finish the unit, pupils take a look at a tale from the viewpoint of a different character and rewrite part or all of a story from this angle.