Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic pain
Treatment: 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 (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)  
The insurer denied coverage for 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 (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)
The denial is overturned.

This case involves a female patient diagnosed with pelvic pain who was being recommended for a pelvic embolization procedure to address pain and swelling and abnormal veins in the pelvis (pelvic varices). The venous lower extremity ultrasound showed left-sided dilated and tortuous anterior thigh vein reflux communicating with left suprainguinal refluxing veins. She had a normal left greater saphenous vein with no evidence of left deep vein thrombosis. Magnetic resonance imaging (MRI) of the pelvis with and without contrast was obtained noting a dilated left gonadal vein and left larger than right pelvic and inguinal varices. The uterine septum was composed of myometrium, there was probable scarring within the left endometrial cavity that remained unchanged, with a probable corpus luteum cyst of the right ovary. The report noted the patient had a past medical history significant for 8 pregnancies and chronic pelvic pain. She complained of left-sided pelvic pain that worsened when standing and with gravity dependent activities and was relieved only with lying down. The patient reported episodes of severe left groin, pelvic, and leg pain that occurred recently, which caused concern for inflammatory thrombophlebitis within the pelvic and vaginal varices.  After the physician reviewed the diagnostic examinations, the recommendation was for embolization.

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

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 (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) has final approval from the appropriate regulatory bodies for this diagnosis and this patient is a good candidate for it.

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 (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) is likely the best available treatment for this patient at this time.

The adverse risks are not increased over standard treatment/services.

This treatment is likely to be at least as beneficial or more beneficial than any of the standard treatments/procedures for this patient.

In summary, the denial of37241 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, varicoceles) and coverage for the requested service/treatment should be overturned.

This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.