Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Pelvic congestion syndrome. 
Treatment: Outpatient services (37241 x 1). 
The insurer denied coverage for outpatient services (37241 x 1). 
The denial is upheld. 

The patient has reported painful varicosities in the left buttock, posterior left thigh, perianally, and in the vulva. The patient has a history of uterine fibroid embolization many years ago. The patient had undergone a diagnostic venogram showing ovarian vein reflux into the pelvis, distal pelvis/proximal, perianal and vulvar region on the left side. The venogram is interpreted as moderate stenosis in the proximal common iliac vein from iliac vein compression and ovarian vein reflux. A plan is noted for embolization of the left ovarian vein. 

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcomes. 

Available data does demonstrate a likely improvement in health outcomes for women undergoing ovarian vein embolization with a diagnosis of pelvic congestion syndrome.
There is a very high degree of technical success and low rate of complications, and the available data from peer-reviewed publications report symptomatic improvement as well as venographic improvement in women from 80-100%. Many would agree that this represents data demonstrating improvement for embolization over no treatment at all. 

However, a meta-analysis of available data makes the statement, "The immediate success rate for the endovascular treatment of pelvic congestion syndrome (PCS) is good and the complication rate low. Most patients report relief in the symptoms for up to 5 years after the procedure. However, there are no randomized or high-quality controlled trials, and the level of evidence therefore remains at C."  Therefore, one is unable to discern if there are long-term improvements for this procedure over other alternatives, such as medical management options. 

Outpatient services (37241 x 1) have final approval from the appropriate regulatory bodies for this diagnosis. 

There is no Food and Drug Administration (FDA) approval or other body approval required for embolization procedures. Embolization of the ovarian veins is a relatively common procedure, and it is accepted as within standard of care. It requires no further approval prior to use in patients. 

The patient is not currently a good candidate for code 37241. 

Therefore, given the lack of data of having superior outcomes to medical management in this patient, without demonstrated discussion or trial of medical management, the ovarian vein embolization is not currently the best available option. As such, the patient is not an optimal candidate currently. 

The requested service of 37241 is not the best available treatment for the patient at this time. 

There is no documentation that this patient has been offered any medical management; therefore, it is not felt that this invasive procedure represents the best available treatment for the patient at this time. 

The possible adverse risks of ovarian vein embolization are increased over medical options, such as progestin treatment. Though, in general, endovascular procedures such as ovarian vein embolization are well tolerated and have a low complication rate. There is always a risk of hemorrhage, thromboembolism and/or infection associated with such procedures. Medical management would have essentially no risk of hemorrhage or infection and is likely to have a risk of thromboembolism lower than that of the recommended endovascular procedure. 

In summary, the denial of outpatient services (37241 x 1) and coverage for the requested 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.