Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Pelvic congestion syndrome
Treatment: Pelvic Embolization
The insurer denied: Pelvic Embolization
The denial is overturned.

The patient is an adult G2P2 (two pregnancies, two births) with chronic pelvic pain. She also has chronic low back pain. She has failed OCPs (oral contraceptive pills), depo provera, lupron, Mirena IUD (intrauterine device), and orilissa. She has had imaging indicating she has pelvic congestion syndrome, May-Thurner, and nutcracker syndrome. The request is for embolization procedure. The request was denied coverage by the health plan as experimental/investigational. This is being appealed.

The health plan should cover the Pelvic Embolization.

The nutcracker syndrome results from compression of the left renal vein at the origin of the superior mesenteric artery. This entrapment can cause symptoms of pelvic venous congestion with retrograde venous flow and a dilated gonadal vein. Treatment can be targeted at the renal vein, gonadal vein, or both. Options include embolization of the gonadal veins, laparoscopic gonadal vein ligation, and/or treatment of the renal vein compression.
In a case series (O'Brien) of 48 women with nutcracker phenomenon, gonadal vein embolization was successfully performed in 96 percent and resulted in long-term benefits in 75 percent.
According to Macher et al, "Pelvic venous disorders encompass a range of conditions such as pelvic congestion syndrome (PCS), May-Thurner syndrome, and nutcracker syndrome. Symptomatically, these conditions may include chronic pelvic pain, back pain, pelvic origin lower extremity and vulvar varicosities, obstructive lower extremity varicosity related symptoms, and renal symptoms including hematuria and flank pain. The vast majority of patients treated for pelvic venous disorders are considered to have PCS [pelvic congestion syndrome], which is a clinical syndrome of chronic pelvic pain in the setting of pelvic venous dilation or incompetence. Symptoms are thought to arise in PCS [pelvic congestion syndrome] is due to dysfunctional venous valves leading to venous insufficiency and reflux. This uncompensated reflux leads to venous dilation and venous hypertension which is hypothesized to activate nociceptors and increase pain sensitivity. The venous incompetence may be congenital, induced during pregnancy, or result from a combination of predisposing factors.
"PCS [pelvic congestion syndrome] is regarded as a challenging diagnosis due to nonspecific findings, absence of definitive criteria and a large differential diagnosis for etiologies of chronic pelvic pain. When evaluating patients with a suspected pelvic venous disorder, other common causes of chronic pelvic pain should be considered. The differential diagnosis includes gynecologic pathologies such as endometriosis and uterine leiomyomas or pathologies stemming from other pelvic or abdominal organs, such as interstitial cystitis, irritable bowel syndrome (IBS), and pelvic floor myalgias. While pelvic venous dilation supports the diagnosis, this finding can also be found incidentally in asymptomatic individuals or may not be the etiology of the patient's pain. Risk factors for PCS [pelvic congestion syndrome] include prior pregnancy, prolonged standing, and underlying venous anomalies. Once diagnosed, PCS [pelvic congestion syndrome] is treated with embolization of the ovarian veins. Various studies have shown rates of success ranging from 64 to 100%.
The literature does support that interventional radiology with venography and embolization are a standard treatment option for pelvic congestion syndrome. This meets the standard of medical practice and is appropriate for her specific condition.