Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Pelvic congestion syndrome.

Treatment: outpatient surgery (37241 x 1).

The insurer denied coverage for outpatient surgery (37241 x 1).

The denial is upheld.

This is an adult patient with a history of pelvic pain attributed to "pelvic congestion syndrome (PCS)". Workup has included ultrasound and Magnetic Resonance Venography (MRV), which showed dilated refluxing ovarian veins with pelvic varicosities.

There is a lack of peer-reviewed literature supporting a better outcome with pelvic vein embolization compared with standard medical treatments. To summarize the current state of the published evidence, randomized studies are needed to determine whether embolization of the internal iliac or gonadal veins is an effective treatment for pelvic congestion syndrome. Given that no randomized trials have been performed in this area, the safety and effectiveness of vein embolization as a treatment for PCS cannot be reliably distinguished from other management approaches, including medical therapy or watchful waiting.

Daniels, J. P.,et al. (2016), "Twenty-one prospective case series and one poor-quality randomized trial of embolization (involving a total of 1,308 women) were identified. Early substantial relief from pain was observed in approximately 75% of women undergoing embolization, and generally increased over time and was sustained. Significant pain reductions following treatment were observed in all studies that measured pain on a visual analog scale. Repeat intervention rates were generally low. There were few data on the impact on menstruation, ovarian reserve, or fertility, but no concerns were noted. Transient pain was common following foam embolization, and there was a &lt; 2% risk of coil migration."

O'Brien, M. T., &amp; Gillespie, D. L. (2015), "Diagnosis of PCS requires a careful history, physical examination, and noninvasive imaging. Several large case series have demonstrated the efficacy of embolotherapy in the reduction of pelvic pain; thus, it is the most favored treatment option for patients with PCS. For patients with outflow obstruction due to nutcracker syndrome, a limited number of studies have demonstrated remission of symptoms with stenting of the left renal vein (LRV) as an alternative to open surgery."

Gavrilov, S. G.,et al. (2021), A decrease in pelvic venous pain intensity was observed at 3.6  1.4 days after endovascular embolization of gonadal veins (EEGV) and 2.5  0.8 days after endoscopic resection of the gonadal veins (ERGV) At 1 month after the intervention, a complete relief of pelvic pain was reported by 52 and 25 patients in the EEGV and ERGV groups, respectively. The relative risk of this complication after EEGV was 1.4. No complications of anesthesia were observed in either group.

Although the proposed embolization codes have been approved by the regulatory bodies, the actual procedure of ovarian vein embolization does NOT have final regulatory approval.

This patient is not a good candidate for outpatient surgery (37241 x 1).

Outpatient surgery (37241 x 1) is not the best available treatment for this patient at this time. Standard medical treatments include compression garments, physical therapy, and hormonal therapy.

This procedure has the theoretical risk of coil migration, contrast reaction, and other complications verses standard medical treatments which include compression garments, physical therapy, hormonal therapy.

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. There is insufficient peer-reviewed literature supporting a better medical outcome of the requested service verses standard medical therapies.

In summary, the denial of outpatient surgery (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.