Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hepatitis C; Cirrhosis; Unintentional weight loss.  
Treatment: Gonadal embolization. 

The insurer denied coverage for gonadal embolization.

The denial is upheld. 

The patient is a female with pelvic pain, severe pain with menses, pelvic fullness, pain with standing and pain with intercourse. The patient was given the diagnosis of pelvic congestion syndrome (PCS). A computed tomography (CT) scan of the abdomen showed that there are prominent pelvic varices and prominent ovarian veins bilaterally which is nonspecific, but has been seen in PCS and there is compression of the proximal left common iliac vein secondary to the right common iliac artery which may represent May-Thurner syndrome. The patient's treating physician is recommending treatment with ovarian vein embolization (OVE). 
 
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 mm diameter on selective transuterine venography in multiparous, premenopausal women with a history of chronic, noncyclic pelvic pain for more than six months. Studies have shown that up to 15 percent of premenopausal women have pelvic varicosities and venous stasis, as demonstrated by pelvic venography, but few experience symptoms.  PCS is thus, 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 the diagnosis of PCS 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 PCS, 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; Surgical ligation of the ovarian vein. However, 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 PCS exists primarily in the form of small case series and cohort studies with mixed results. 
 
Tu et al. (2010)'s 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-related pelvic pain remains unclear, and controlled trials comparing medical and interventional treatments are urgently needed for PCS-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. 

The requested procedure is not considered medically necessary.
The health plan acted reasonably with sound medical judgement and in the best interest of the patient.
The carrier's denial of coverage for the requested procedure- Gonadal Embolization should be upheld. The medical necessity is not substantiated.