Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Pelvic Pain

Treatment: procedure code 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 (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, and varicoceles) to treat R10.2 pelvic and perineal pain.

The insurer denied coverage for procedure code 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 (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, and varicoceles) to treat R10.2 pelvic and perineal pain.

The denial is upheld.

The patient is a female with a history of pelvic pain status post left ovarian vein embolization. She presented to the Interventional Radiologist's office for a consultation about pelvic pain. She has reported pelvic pain. Her pelvic pain resolved after the procedure. It recurred months prior to arrival for the Interventional Radiology evaluation. Magnetic resonance imaging (MRI) of the pelvis was done. It revealed a recanalized refluxing left ovarian vein and a dilated right ovarian vein. The physician recommended ovarian vein embolization to treat 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 pelvic congestion syndrome, 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. 

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 pelvic congestion syndrome (PCS) exists primarily in the form of small case series and cohort studies with mixed results. 

A systematic review of the literature showed that treatment studies (using transvenous catheter embolization, surgical ligation, hysterectomy, or hormonal suppression) found improvement from 24% (percent) 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. 

The procedure is considered experimental/ investigational and not medically necessary. The procedure 37241 times (x) 1, closing of blood vessels in the pelvis is not considered more beneficial for this patient's diagnosis. The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. The outpatient procedure 37241 x 1, does not need approval from the appropriate regulatory bodies for this diagnosis. Due to lack of scientific evidence of health improvement, it is unknown if this patient is a good candidate for outpatient procedure 37241. The outpatient procedure 37241 is not the best available treatment for this patient at this time. The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. The adverse risks are increased over standard treatment/services.

The carrier's denial of procedure code 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 (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, and varicoceles) to treat R10.2 pelvic and perineal pain should be upheld.