Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic pain
Treatment: 37241 vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)
The insurer denied coverage for 37241 vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)
The denial is overturned.

This case involves a patient diagnosed with pelvic congestion syndrome who is being recommended for pelvic embolization. Magnetic resonance imaging (MRI) of the pelvis showed an enlarged left gonadal vein measuring 9 millimeters (mm) with large dilated pelvic floor varices, communication from the left ovarian vein to the left suprainguinal veins, then extending into the anterior soft tissues of the thigh. Pelvic floor varices were larger on this study compared to previous MRI. Ultrasonography showed no left lower extremity deep vein thrombosis or great saphenous vein reflux, but an extensive complex network of enlarged and tortuous veins in the anterior thigh extending medially to the left ankle and foot, all communicating with the pelvis via suprainguinal veins, and correlating with findings seen on the MRI.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes.

37241 vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) has final approval from the appropriate regulatory bodies for this diagnosis.

This patient is a good candidate for 37241 vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) and it is likely the best available treatment for this patient at this time.

The adverse risks are not increased over standard treatment.

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

Medical literature has noted that in terms of treating pelvic congestion syndrome, the most recent available research favors endovascular treatment with interventional radiology over surgical management as medical and surgical treatments have been shown to be less effective than transcatheter pelvic vein embolization.

In summary, the denial of 37241 vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) and coverage for the requested service/treatment should be overturned.

This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.