Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic Pain.
Treatment: 37238 - Open/Percutaneous placement intravascular stent same first;
37239 - Open/percutaneous placement intravascular stent same each additional;
37248 - Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretations necessary to perform the angioplasty within the same vein; initial vein;
37249 - Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; each additional vein.

The insurer denied the 37238 - Open/Percutaneous placement intravascular stent same first; 37239 - Open/percutaneous placement intravascular stent same each additional; 37248 - Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretations necessary to perform the angioplasty within the same vein; initial vein; 37249 - Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; each additional vein.  The denial is upheld.

The patient is a female with pelvic congestion syndrome requesting ovarian vein embolization. There is no request in the records provided for review for angioplasty or stenting.

No, the proposed treatment of stenting and angioplasties (CPT codes 37238, 37239, 37248, and 37249) is not medically necessary.

There is no request for angioplasty or stenting in the records submitted for review. Stenting and angioplasties (CPT codes 37238, 37239, 37248, and 37249) have not been requested; rather the patient is requesting ovarian vein embolization. CPT codes 37238, 37239, 37248, and 37249 are not typical procedures done to treat this patient's symptoms/diagnosis and are not used in ovarian vein embolization.  

Ovarian and internal iliac vein embolization is a procedure and does not need Food and Drug Administration (FDA) approval and also does not require Institutional Review Board (IRB) approval.

There are no phase I, II or III clinical trials or determinations of safety in comparison to conventional alternatives or toxicity regarding ovarian and internal iliac vein embolization for pelvic congestion syndrome found by a search at ClinicalTrials.gov.  However, a search on PubMed finds many articles concerning the treatment of pelvic congestion syndrome with the overall conclusion that ovarian and internal iliac vein embolization is efficacious, safe, has been performed for many years, and, along with surgery, is standard of care for the treatment of pelvic congestion syndrome (PCS).

A peer-reviewed prospective trial by Kim of 131 patients found that: "embolotherapy can achieve significant improvement in pain perception levels in patients with chronic pelvic pain caused by pelvic venous congestion."  A prospective study of 56 patients performed by Venbrux found that: "For patients with ovarian/internal iliac varices, transcatheter embolotherapy provides a nonsurgical treatment option. There is a significant decrease in pain based on VAS [visual analog scale] without any notable impact on menstrual cycle." A review article states that ovarian vein embolization results are "equivalent to those of surgery and better than conventional medical therapy." Several quotes from other peer-reviewed published review articles state that "[o]varian vein embolization using coils is a safe and effective therapeutic method for treatment of PCS [pelvic congestion syndrome] " and "[o]varian and/or internal iliac vein embolization appears to be a safe, well-tolerated, effective treatment for pelvic congestion syndrome." A retrospective paper of 113 patients by Nasser found that "Transcatheter embolization was safe and effective for PCS [pelvic congestion syndrome] ." A review paper by Smith states that "Limited clinical evidence supports the use of embolotherapy in the management of pelvic congestion syndrome." A randomized prospective trial by Guirola found that "Embolization for PCS [pelvic congestion syndrome] resulted in pain relief in 90% of patients; clinical success was not affected by embolic device." A peer-reviewed systematic review paper by Brown states that "PCS [pelvic congestion syndrome] is a prevalent and treatable condition for which percutaneous treatment is safe and effective...Catheter-directed venography demonstrates improved sensitivity in detecting venous insufficiency compared with noninvasive imaging, as well as the benefit of simultaneous diagnosis and treatment, and a high rate of success in improving clinical symptoms."

Therefore, while ovarian vein embolization is an appropriate treatment for pelvic congestion syndrome, CPT codes 37238, 37239, 37248, and 37249 have not been requested for this patient and are not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient in denying CPT codes 37238, 37239, 37248, and 37249.