Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic pain
Treatment: 37241 vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)
The insurer denied coverage for 37241 vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)
The denial is upheld.

The patient has a history of eight pregnancies and has pelvic and left lower extremity (LLE) pain due to varicosities. A magnetic resonance imaging (MRI) and ultrasound (US) confirm pelvic varicosities and a nine millimeter (mm) refluxing left ovarian vein. The treating provider is requesting to perform ovarian vein embolization, which the plan is denying as experimental therapy.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes.

There is a lack of peer-reviewed literature supporting the efficacy of pelvic vein embolization as being superior to standard medical treatments.

37241 vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) does not have final approval from the appropriate regulatory bodies for this diagnosis.

The body of evidence in the peer-reviewed medical literature regarding embolization of the ovarian vein or internal iliac veins for the treatment of pelvic congestion syndrome (PCS) is insufficient and poor quality. While some studies suggest favorable results of embolization for the treatment of pelvic congestion syndrome (PCS), additional well-designed randomized controlled trials are necessary to establish the relative safety and efficacy of the embolization procedure.

Although this does not have final approval from the appropriate regulatory bodies for this diagnosis, based upon the history and MRI findings, the patient would be a suitable candidate for the proposed procedure, however, peer-reviewed literature does not support the procedure verses other standard medical treatments.

37241 vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) is not the best available treatment for this patient at this time.

Although there are few significant adverse risks associated with this procedure when performed by a competently trained physician, as would be the case in this circumstance, there would be a slight risk of adverse events compared with standard medical treatments of hormonal therapy or compression garments.

Per Daniels, J. P., et al., (2016), "Embolization appears to provide symptomatic relief of CPP in the majority of women and is safe, although the quality of the evidence is low."

In summary, the denial and coverage for the requested service/treatment should be upheld.

This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.