Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Pelvic congestion syndrome.

Treatment: outpatient surgery (37241 x 1).

The insurer denied coverage for outpatient surgery (37241 x 1).

The denial is upheld.

The patient has a chief complaint of pelvic pain. The patient was reportedly diagnosed with pelvic congestion syndrome. Ovarian vein studies revealed bilateral dilatation of ovarian veins with reflux. The treating physician requested coverage for outpatient surgery (37241 x 1).

Pelvic congestion syndrome (PCS), also known as chronic pelvic pain syndrome or pelvic venous incompetence, is caused by utero-ovarian varices. PCS is defined by engorged pelvic veins of more than 10 millimeters (mm) diameter on selective transuterine venography in multiparous, premenopausal women with a history of chronic, noncyclic pelvic pain for more than six months.
Up to 15 percent of premenopausal women have pelvic varicosities and venous stasis, as demonstrated by pelvic venography, but few experience symptoms. Pelvic congestion syndrome is the term used to describe the subset of these women who have pain and other symptoms in the uterus, ovaries, and vulva that cannot be attributed to any other cause. Although this diagnosis remains controversial, there is evidence that some women with pelvic varicosities and venous stasis, as demonstrated by pelvic venography, have associated chronic pelvic pain.

Two randomized clinical trials suggest that medical treatment with gonadotropin-releasing hormone agonists or synthetic progestins effectively decrease pain associated with pelvic congestion:

Other treatments for pelvic congestion syndrome, which have not been subjected to randomized clinical trials, include:

1)Hysterectomy and bilateral salpingo-oophorectomy.
2)Embolization of the ovarian veins with or without the internal iliac veins.
3)Sclerotherapy.
4)Surgical ligation of the ovarian vein. 

Efficacy of these treatments is supported only by observational data and case reports. 

Additional well-designed randomized controlled trials are needed to evaluate the safety and effectiveness of embolization therapy as a treatment for PCS.

Note that the procedure may have the following complications:

Those related to drug administration, such as narcosis, sedation or rarely hypersensitivity, for example to iodinated contrast (reported in less than 1 % of patients with non-ionic contrast).

Venous puncture related, such as hematoma, pneumothorax (for venous catheterization via a neck vein).

Embolization of non-target vessels, such as coil misplacement, such as left ovarian vein involving left renal vein, obturator or circumflex coil protruding into left external iliac or common femoral vein. Caution is advised with liquid embolic agents as communications have been shown to exist between the ovarian veins and paravertebral veins and specifically between the left ovarian vein and splenic, ureteric and inferior mesenteric veins.

In summary and based on all of the above, the procedure is not considered medically necessary.

The procedure 37241 x 1, closing of blood vessels in the pelvis is not considered more beneficial for this patient's diagnosis.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes.

The outpatient procedure 37241 x 1, does not need approval from the appropriate regulatory bodies for this diagnosis.

Due to lack of scientific evidence of health improvement, it is unknown if this patient is a good candidate for outpatient procedure 37241.

The outpatient procedure 37241 is not the best available treatment for this patient at this time.

The adverse risks are increased over standard treatment/services.

In summary, the denial of outpatient surgery (37241 x 1) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.