Appeal type: Experimental/Investigational
Decision: Upheld

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

The patient is an adult female with a diagnosis of pelvic pain and endometriosis. The patient has tried multiple hormonal treatments with no improvement. She was diagnosed with pelvic congestion syndrome, and the plan is to proceed with ovarian vein embolization.

The health plan should not cover the Pelvic Embolization.

Pelvic congestion syndrome (PCS), also known as chronic pelvic pain syndrome or pelvic venous incompetence, is caused by utero-ovarian varices. PCS (pelvic congestion syndrome) is defined by engorged pelvic veins of more than 10 mm millimeter) 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 hysterectomy and bilateral salpingo-oophorectomy; embolization of the ovarian veins with or without the internal iliac veins; sclerotherapy; and surgical ligation of the ovarian vein. The efficacy of these treatments is supported only by observational data and case reports. Evidence in the published peer-reviewed medical literature investigating the use of embolization for pelvic congestion syndrome (PCS) exists primarily in the form of small case series and cohort studies with mixed results. A systematic review of the literature showed that treatment studies (using transvenous catheter embolization, surgical ligation, hysterectomy, or hormonal suppression) found improvement from 24% to 100%; a similarly wide range of improvement was found with change in continuous rating of visual analogue scale pain scores (mean follow-up 4 months to 5.6 years). The optimal diagnostic approach for PCS (pelvic congestion syndrome)-related pelvic pain remains unclear, and controlled trials comparing medical and interventional treatments are needed for PCS (pelvic congestion syndrome)-associated pelvic pain. Additional well-designed randomized controlled trials are needed to evaluate the safety and effectiveness of embolization therapy as a treatment for PCS (pelvic congestion syndrome).
In summary and based on all of the above, the requested procedure is considered experimental/investigational and not medically appropriate.