Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic congestion syndrome. 
Treatment: Outpatient procedure 37241 x 1, closing of blood vessels in the pelvis. 

The insurer denied coverage for outpatient procedure 37241 x 1, closing of blood vessels in the pelvis.  The denial is overturned. 

This is a female patient with a history of pelvic congestion syndrome (PCS), varicose veins, and thrombophlebitis.  She presented to the vascular surgeon's office for the re-evaluation of lower extremity varicose veins and pelvic pain.  There was a large amount of varicose veins in both lower extremities.  The patient stated that she had laparoscopic surgery by the Gynecologist and was found to have a large right ovarian vein.  The treating practitioner recommended obtaining a computed tomography (CT) venogram of the abdomen and pelvis to reassess PCS.  Imaging was done and the physician recommended ovarian vein embolization (OVE) to treat PCS. 

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome with procedure 37241 x 1, closing of blood vessels in the pelvis. 

"Chronic pelvic pain (CPP) in the presence of dilated and refluxing pelvic veins is often described as pelvic congestion syndrome (PCS), although the causal relationship between pelvic vein incompetence and CPP has not been established. Percutaneous embolization is the principal treatment for PCS, with high success rates cited" (Daniels et al. 2016). 

The outpatient procedure 37241 x 1, closing of blood vessels in the pelvis does have final approval from the appropriate regulatory bodies for this diagnosis. It is Food and Drug Administration (FDA) approved. 

This patient is a good candidate for outpatient procedure 37241 x 1, closing of blood vessels in the pelvis need. The patient has history of symptomatic pelvic congestion syndrome. There are high quality prospective clinical outcomes reported in the medical literature (including a systematic review) which confirms benefit of the requested procedure in this patient population. 

"Pelvic venous insufficiency is now a well-characterized etiology of pelvic congestion syndrome (PCS) ... In addition to individual physical, emotional, and quality-of-life implications of CPP, there are profound healthcare and socioeconomic expenses with estimated annual direct and indirect costs in the United States in excess of 39 billion dollars. PCS consists of clinical symptoms with concomitant anatomic and physiologic abnormalities originating in venous insufficiency... (Brown et al. 2018).   

The outpatient procedure 37241 x 1, closing of blood vessels in the pelvis is the best available treatment for this patient at this time. This is the most appropriate treatment option for the patient per the current peer reviewed medical literature. 

"The immediate success rate for the endovascular treatment of PCS is good and the complication rate low. Most patients report relief in the symptoms for up to 5 years after the procedure" (Mahmoud et al. 2016). 

"Embolization for PCS resulted in pain relief in 90% of patients; clinical success was not affected by embolic device..." (Guirola et al. 2018). 
  
The adverse risks are not increased over standard treatment/services. 

The carrier's denial of coverage for outpatient procedure 37241 x 1, closing of blood vessels in the pelvis should be overturned.