Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #3:

Diagnosis: Chronic pelvic pain.

Treatment: vein embolization (procedure code 37241).

The insurer denied coverage for vein embolization (procedure code 37241).

The denial is upheld.

The patient is an adult female. Medical records report symptoms characteristic of pelvic congestion syndrome PCS), with pelvic pain, dyspareunia, and vaginal/labial varices. Computed tomography (CT) Venogram report does not document evidence of pelvic varicosities. Office notes state that pelvic varicosities are present on CT venogram, contrary to the report of the study.

All available medical documentation was reviewed.

There is scientific evidence in peer-reviewed literature that supports a result of improvement in health outcomes for patients with characteristic symptoms and evidence of pelvic varices. Medical records support the patient has characteristic symptoms; however, there is no evidence of pelvic varices. The CT venogram report specifically documents the absence of noted pelvic vein abnormalities.

Brown, C. L., Rizer, M., Alexander, R., Sharpe, E. E., 3rd, & Rochon, P. J. (2018), "Pelvic venous insufficiency is now a well-characterized etiology of pelvic congestion syndrome (PCS). The prevalence of chronic pelvic pain (CPP) is 15% in females aged 18 to 50 years in the United States and up to 43.4% worldwide. In addition to individual physical, emotional, and quality-of-life implications of CPP, there are profound healthcare and socioeconomic implications. PCS consists of clinical symptoms with concomitant anatomic and physiologic abnormalities originating in venous insufficiency. The etiology of PCS is diverse involving both mechanical and hormonal factors contributing to venous dilatation (>5 millimeters (mm)) and insufficiency. Factors affecting the diagnosis of PCS include variance of causes and clinical presentations of pelvic pain and relatively low sensitivity of noninvasive diagnostic imaging and laparoscopy to identify insufficiency compared with catheter venogram."

Mahmoud, O., Vikatmaa, P., Aho, P., Halmesmaki, K., Alback, A., Rahkola-Soisalo, P., Lappalainen, K., & Venermo, M. (2016), "Twenty studies with a total of 1081 patients were included in the review. There were no randomized trials, and only one study included a control group. The immediate technical success rate in the occlusion of the affected veins was 99%. Seventeen studies reported the 1- to 3-month clinical success of 641 patients. Of these, 88.1% reported moderate to significant relief in the symptoms and 11.9% reported little or no relief. In 17 studies, long-term results were reported, and the follow-up varied between 7.3 months and 5 years. In late follow-up, 86.6% reported relief of the symptoms and 13.6% experienced little or no relief... Conclusions: The immediate success rate for the endovascular treatment of PCS is good and the complication rate is low. Most patients report relief in the symptoms for up to 5 years after the procedure."      

There is no regulatory obstacle to the performance of this well-accepted procedure for appropriately selected patients.     

Based on the CT Venogram report, evidence of the patient having an abnormality appropriately treated by pelvic vein embolization is lacking. Physician records report that there are pelvic varices, which would qualify the patient for treatment. However, the CT Venogram report does not support this finding. Therefore, the requested procedure does not qualify as standard of care unless or until the discrepancy between the CT Venogram report and the physician records is addressed and evidence of treatable pelvic vein reflux or varicosities is provided. 

The vein embolization (procedure code 37241) is not the best available treatment for this patient at this time. Based on the CT Venogram report, evidence of the patient having an abnormality appropriately treated by pelvic vein embolization is lacking.     
  
The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. Without documented evidence of treatable pelvic venous abnormalities such as reflux or varices, the procedure cannot be seen as more likely to be beneficial than noninterventional care.                                                    

In summary, the denial of Vein Embolization (procedure code 37241) 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.