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 reversed.

The patient is a female with complaints of pelvic pain with ovarian vein reflux status post treatment with recurrent symptoms. The documentation does indicate she has a history of migraines as well as endometriosis and complex pelvic pain status post left ovarian vein embolization. Her symptoms started a while ago and she was treated for recurrent yeast infection for many years. Her pain worsened, and she was treated with pudendal nerve blocks as well as Botox, pelvic floor physical therapy and multiple medications which provided no relief. She was found to have a dilated left ovarian vein with reflux and underwent embolization of the left pelvic venous network and left ovarian vein. The documentation indicated her pelvic pain had resolved immediately following embolization and she has been pain-free over years until months ago when her symptoms recurred. She indicated her symptoms are similar to the ones she had prior to embolization. She states symptoms are worse with gravity dependent activity as well as sexual intercourse. The physical examination revealed no significant findings. An magnetic resonance image (MRI) was referenced indicating a left ovarian vein measuring 11 millimeter (mm) and dilated right ovarian vein measuring 8 mm. The physician indicated she presented with recurrent nearly identical symptoms of pelvic pain as well as heaviness and pressure associated with gravity dependent activities. The MRI showed a recanalized refluxing left ovarian vein and a dilated right ovarian vein. It was recommended she undergo a repeat left ovarian vein and possible right ovarian vein embolization to treat her pelvic pain and pelvic varices that were arising from the ovarian vein reflux.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome for patients with pelvic congestion syndrome treated with gonadal vein embolization. This patient had long-term symptomatic improvement following a prior gonadal embolization procedure. 

Gonadal vein embolization is the best available treatment for this patient at this time. It is a well-documented minimally invasive procedure for the treatment of pelvic congestion syndrome with peer-reviewed literature demonstrating measurable improvement in patient pain and quality of life following the procedure. There are not many well documented surgical options for pelvic congestion syndrome, except for hysterectomy. 

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 reversed.