Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic congestion syndrome. 
Treatment: Code 37241 - ovarian vein embolization. 
The insurer denied coverage for code 37241 - ovarian vein embolization. 
The denial is overturned. 

The patient presented with symptoms characteristic of pelvic congestion syndrome. Imaging demonstrated refluxing ovarian veins, the common anatomic correlate of symptoms of pelvic congestion syndrome. These veins were treated with catheter directed embolization previously without complication. Persistent symptoms have been reported, resulting in further imaging demonstrating additional pelvic veins with reflux. The provider has requested a repeat venogram with probably further embolization. The patient's insurer has denied payment. The denial is under review. 

The scientific evidence in peer-reviewed literature support a result of improvement in health outcome. 

The reviewer recognizes that the request for repeat embolization is unusual, and raises the possibility that the patient has symptoms of a different origin. Pelvic symptoms could arise from gastrointestinal (GI), urinary, or neurogenic causes. However, in the setting of imaging showing significant reflux in the adnexal veins, an additional effort to relieve symptoms with embolization is appropriate. 

According to multi-society evidence based peer reviewed expert consensus guidelines published in the most respected journal in the field as long ago as 2011. "We suggest treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs, or transcatheter sclerotherapy, used alone or together" (Gloviczki, 2011). 

Pelvic and gonadal vein embolization is well documented to be safe and effective and is commonly practiced as the "standard of care" in these settings. 

Code 37241 - Ovarian Vein Embolization (treatment for pelvic congestion syndrome) does not have final approval from the appropriate regulatory bodies for this diagnosis, however, interventional procedures of this nature are not subject to regulatory approval. 

This patient is a good candidate for code 37241 - Ovarian Vein Embolization (treatment for pelvic congestion syndrome). 

Female patients in this age group without major medical contraindications to catheter based intervention such as severe contrast allergy, or severe cardiopulmonary disease are good candidates for this procedure in the presence of characteristic symptoms of pelvic congestion syndrome. This patient fits the profile of a good candidate for the procedure. 

Literature cited below offers no satisfactory alternative to the procedure. The insurers determination is in effect a determination that patients with this condition should be left without treatment for the condition. 

The adverse risks are not increased over standard treatment/services. 

The recommended treatment is the standard treatment, so it does not have adverse risks above standard treatment. 

The treatment performed is the recommended standard of care for patients with the condition and imaging findings documented in this case and is likely to be more beneficial than other procedures. 

In summary, the denial of code 37241 - Ovarian Vein Embolization (treatment for pelvic congestion syndrome) and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.