Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #2:

Diagnosis: Pelvic congestion syndrome.

Treatment: vascular embolization or occlusion.

The insurer denied coverage for vascular embolization or occlusion.

The denial is overturned.

The patient has symptoms of pelvic pain and pressure, and increasingly heavy menses. 

She has been diagnosed with pelvic congestion syndrome (PCS). This is based on an ultrasound and a computed tomography (CT) scan. The ultrasound showed prominent bilateral peri-uterine vessels. The CT scan showed a dilated right ovarian vein and multiple tortuous para-uterine veins with an impression of pelvic congestion syndrome. 

A note indicates that a Spanish interpreter was present while the treating provider explained the procedure of ovarian vein embolization. The note also states that alternatives were discussed (though not specifically noted), and that the option of oral contraceptives was ruled out because the claimant has a history of migraine headaches with aura. 

All available medical documentation was reviewed.

Scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes with the requested procedure. There are multiple articles in medical literature that attest to the effectiveness and safety of ovarian vein embolization.

Transcatheter embolization of the ovarian veins is a safe and feasible technique leading to complete relief of symptoms in more than half of cases (Maleux et al., 2000)

"Improvement in pain symptoms should be expected in 80 to 90% of the patients, with significant improvement in 60% of the patients. Treatment appears durable at 5-year follow-up." (Durham & Machan, 2013)

"Pelvic congestion syndrome (PCS) is a common cause of chronic pelvic pain in women of reproductive age. Pain that is intermittent or constant lasting for 3-6 months, present in the pelvic or abdominal region, occurring throughout the menstrual cycle, and without any association with pregnancy is chronic pelvic pain." (Saadat & Singh, 2022)

The reviewer is not aware of the necessity for approval from regulatory bodies.     

This patient is a good candidate for vascular embolization or occlusion. Her symptoms are compatible with pelvic congestion syndrome and are affecting her quality of life. Also, ultrasound and CT studies showed results that are compatible with this diagnosis. Finally, the treating provider has stated that alternative options have been discussed with the patient in the presence of a Spanish interpreter.     

Vascular embolization or occlusion is the best available treatment for this patient at this time. 

Because this is an operative procedure (versus medical options), the risk is probably somewhat higher, but literature indicates that the risks are nevertheless low, and are outweighed by the benefits.     

The procedure of ovarian vein embolization is more definitive than the alternatives. According to the records provided for review, the claimant has not had success with alternative treatments, she has been counseled regarding alternatives, and has chosen this procedure. 

In summary, the denial of vascular embolization or occlusion 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 risks are not substantially increased over standard treatments.