Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Patient 1: The patient is a 34-year-old female who has a history of pain in her right leg and vulva area, which occurs with ovulation and with the first day of her period. She apparently has a problem with varicose veins in the right lower extremity, which needs to be addressed and treated by the appropriate procedure. In June 2004, a pelvic MRI revealed early filling and prominence of the right ovarian vein, which may indicate pelvic congestion syndrome. The patients radiologist recommended an ovarian vein venography followed by embolization. The Health Plan has denied authorization for the requested procedure indicating it is considered investigational for treatment of the patients medical condition. Although treatment of the patients problem with her right lower extremity is indicated, diagnosis and suggested treatment of a gynecologic symptom by a radiologist is not within the standard of practice. The patient requires a gynecologic evaluation for pelvic pain, which may include a genito-urinary evaluation by an urologist and a neuromuscular evaluation by a neurologist. A laparoscopy might be considered as well as a trial of gonadotrophin agonist releasing hormones to stop ovulation and produce amenorrhea to evaluate the effect on the patients symptoms.Based upon the information set forth above, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 2: The patient is a 34-year-old female with a two-year history of night leg pain originating in the right vulvar area and radiating to the right leg. In addition to edema of her right extremity, the patient states that the pain is cyclic in nature. The patient was seen by a vascular surgeon who did not feel that the degree of night leg venous insufficiency explained the symptom complex. The patient underwent an MRI scan, which demonstrated what appeared to be an enlarged right ovarian vein and questionable enlargement of the left ovarian vein. Additional findings include enlarged venous channels in the pelvis. The radiologist requested authorization for emobilization of the ovarian veins after venogram verification of the ovarian reflux by ovarian vein venography. The Health Plan has denied coverage for the requested procedure on the basis that it is considered investigational. While the diagnosis of pelvic congestion is that of exclusion, most authorities are in agreement regarding the symptom complex. These manifestations include chronic pelvic pain - intermittent or constant, dysmenorrhea, dyspareunia, postcoital pain aggravated by standing, urinary urgency or constipation. In this case, there is no description in the record of such a symptom complex. The patient complains of vulvar pain associated with varicosities. While the record is well documented regarding the possible treatment option of pelvic congestion, there is no indication of symptoms, which describe this syndrome either by the patient, the office record or the consultants. There is only the unexplained presence of painful vulvar varicosities and varicosities of the right lower extremity. The diagnosis of pelvic congestion syndrome is not substantiated. The vascular insufficiency of the lower extremity as an etiology is unexplained; insufficiency of the gonadal vessels alone does not account for the patients lower extremity problem. Standard vascular procedures should be addressed in the management of this patient. Based upon the information set forth above, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 3: The patient is a 34-year-old female. Since her second delivery 2.5 years ago she has had symptomatic varicose veins. She has right leg pain both front and back. There is dissention on the back of the leg. There are multiple enlarged veins on the posterior calf to the inner thigh. Her pain increases throughout the day and is worse with her menses. The patient is no longer obtaining relief from compression stockings and elevation. Duplex ultrasound reveals varicosities of the right lower extremity into the inguinal ligament and the anteromedial upper third of the thigh. The reflux extends throughout the saphenous vein into the thigh. The left leg is normal. Pelvic MRI suggests adenomyosis. There is early filling and prominence of the right ovarian vein. A request has been made for an ovarian vein venography followed by embolization. The Health Plan has denied the request on the basis that the requested procedure is considered experimental.Therapy for her lower extremity varicosities is likely to be more effective than therapy for pelvic congestion syndrome. The patients symptoms appear clearly related to extremity vein insufficiency. Ultrasound diagnosis confirms the symptoms and physical exam. If treatment of this disorder fails to cure her pain, than a search for secondary causes is appropriate. However, her symptoms are not primarily chronic pelvic pain, but lower extremity pain. Furthermore, while pelvic congestion syndrome has become accepted as a cause of chronic pelvic pain, ovarian vein embolization remains an unproven procedure. Therefore, standard vascular procedures should be utilized in the management of this case. As such, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.