Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Left sided scrotal varicocele

Treatment: Vein embolization to treat a varicocele, procedure code 37241

The insurer denied coverage for vein embolization to treat a varicocele, procedure code 37241

The denial is overturned.

This case involves a who presented to the radiologist office with a left-sided scrotal varicocele. He reported left scrotal pain rated 4-5/10 (on a pain scale of 1-10) in severity that worsened with sitting and with activity and improved at night. He denied urinary symptoms, hematuria, abdominal pain, or flank pain and denied having urinary tract infections or kidney stones. The pain occurs constantly and after evaluation, the patient was recommended for a trans jugular left gonadal vein coil embolization. Scrotal ultrasound demonstrated a large left-sided varicocele. The patient received a notice of denial regarding the vein embolization procedure stating that there was insufficient proof that this procedure improves health. The requested procedure was denied based on the medical policy vein embolization as a treatment of pelvic congestion syndrome and varicocele. An appeal stated that the patient's quality of life been interrupted by left-sided scrotal pain, which was only attributed to a large varicocele. The physician stated that gonadal vein embolization is needed to treat the large scrotal varicocele. This review pertains to the denial of coverage for vein embolization to treat a varicocele, procedure code 37241. 

Scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.  This really pertains to reduction of pain due to resolution of congestion in the pelvis and/or scrotal region.

Vein embolization to treat a varicocele, procedure codes 37241 have final approval from the appropriate regulatory bodies for this diagnosis.

This patient is a good candidate for vein embolization to treat a varicocele, 37241.

The embolization to treat a varicocele, procedure code 37241 is one of the best available treatments for this patient at this time. Microsurgical techniques are also appropriate as an alternative method with embolization typically indicated for unilateral needs.

The adverse risks are actually reduced over standard treatment services as the treatment minimizes or limits the risks of arterial and differential injury compared to surgical techniques.

Given the patient's left sided scrotal varicocele, it was determined that the requested service is likely to be more beneficial than any of the standard treatment/procedures.

Literature states that Percocet remains the most identified correctable cause of male factor infertility with prevalence rates of 25.4% to 81% of infertile men. In North America, surgical correction is the most employed technique for rectocele repair. An attractive alternative to surgical rectocele repair is the selective catheterization and embolization of the gonadal veins using sclerosing agents, tissue adhesives, or detachable metallic coils. This radiologic approach is minimally invasive and has a quicker recovery time as well as several other advantages. Embolization can be performed under local anesthesia, thus limiting the risks associated with general anesthesia. This approach also allows excellent real-time delineation of venous anatomy and confirmation of venous occlusion using venography at the time of rectocele repair.  As embolization is purely intravascular it minimizes or limits the risks of arterial and differential injury compared to surgical techniques, which has obvious implications in the management of the infertile male. In the case of this patient, he had a left-sided scrotal varicocele, likely due to pelvic congestion. Based upon current medical literature, the proposed treatment would be indicated over the microsurgical procedures, which are typically utilized for bilateral conditions. Evidence has shown that embolization reduces the pain associated with congestion causing the symptoms such as the discomfort reported by the patient.  

The carrier's denial of vein embolization to treat a varicocele, procedure code 37241 should be overturned.