Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Varicose veins and pelvic congestion. 
Treatment: Vascular embolization. 
The insurer denied coverage for vascular embolization. 
The denial is overturned. 

This case involves a female with a history of severe varicose veins and pelvic congestion who is being recommended for vascular embolization. The pelvic-ovarian vein Doppler report noted that the patient had dilated ovarian veins with reflux. Her right ovarian vein was found to be 3.4 millimeters (mm) to 2.2 seconds of reflux compared to the left ovary vein measuring 4.4 mm with over 6 seconds of reflux. Magnetic resonance venogram demonstrated large varicose veins with bilateral reflux with pelvic varices compatible with pelvic congestion syndrome. Diagnostic pelvic venogram noted deep vein reflux in the bilateral common iliac vein with Valsalva. There was left common femoral vein and greater saphenous vein reflux, left common iliac origin approximate 80% stenosis with intravascular ultrasound (IVUS), left internal iliac vein reflux with no source of reflux identified into the labial plexus through internal iliac or left saphenous femoral vein area with Valsalva and tilt table test. The left renal vein was patent with left gonadal vein reflux. Recommendation was for left versus right gonadal vein treatment initially. An email correspondence from the patient stated that she had suffered from severe varicose veins and pelvic congestion through all 5 of her pregnancies. She previous had procedures done on her legs to alleviate pain and pressure. These measures helped slightly but did not alleviate the pain and pressure felt in her pelvis with the large veins stemming from the groin traveling to the knee. She tried compression knee-high stockings, compression thigh-high stockings, tight compression bike shorts, resting throughout the day, elevating her legs, the use of ice/hot packs, and maintaining healthy weight. These would help to alleviate pain momentarily but was not long-term. The patient claimed to lead a very active lifestyle and was on her feet most of the day, with varicose veins in the upper thigh feeling full and on fire by lunch. She endorsed that her groin area and vulva were covered with varicose veins and felt very heavy and achy. She often had pain in her lower abdomen and had experienced abnormal menstrual bleeding in the past year and a half. She also endorsed increasing pain after intercourse. This review pertains to the vascular embolization. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. 

Vascular embolization does not need to have final approval from the appropriate regulatory bodies for this diagnosis. 

This patient is a good candidate for vascular embolization. 

The vascular embolization is one of the best available treatments for the patient at this time. 

The adverse risks are not increased over standard treatment/services. 

Current medical literature has stated that pelvic venous congestion syndrome (PVCS) is challenging and complex because of chronic pelvic pain in female patients. When PVCS is caused by incompetent gonadal vein valves, treatment typically is performed by means of embolization via a minimally invasive catheter with excellent technical and clinical success rates. Literature also notes that complications with embolization are not common. Given that the patient was found to have severe varicose veins, pelvic congestion, and reflux for multiple diagnostic studies in addition to failure to respond to conservative treatment, proceeding with vascular embolization would be a reasonable course of care for this individual. 

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of vascular embolization should be overturned.