Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic congestion syndrome. 
Treatment: Outpatient procedure 37241 x 1, closing of blood vessels in the pelvis. 

The insurer denied coverage for outpatient procedure 37241 x 1, closing of blood vessels in the pelvis.  The denial is upheld. 

This is a female patient with a history of pelvic congestion syndrome (PCS), varicose veins, and thrombophlebitis.  She presented to the vascular surgeon's office for the re-evaluation of lower extremity varicose veins and pelvic pain.  There was a large amount of varicose veins in both lower extremities.  The patient stated that she had laparoscopic surgery by the Gynecologist and was found to have a large right ovarian vein.  The treating practitioner recommended obtaining a computed tomography (CT) venogram of the abdomen and pelvis to reassess PCS.  Imaging was done and the physician recommended ovarian vein embolization (OVE) to treat PCS. 

Two randomized clinical trials suggest that medical treatment with gonadotropin-releasing hormone agonists or synthetic progestins effectively decrease pain associated with pelvic congestion.

Other treatments for pelvic congestion syndrome, which have not been subjected to randomized clinical trials, include:  1) Hysterectomy and bilateral salpingo-oophorectomy, 2) Embolization of the ovarian veins with or without the internal iliac veins, 3) Sclerotherapy, and 4) Surgical ligation of the ovarian vein. 

Efficacy of these treatments is supported only by observational data and case reports. 
Evidence in the published peer-reviewed medical literature investigating the use of embolization for PCS exists primarily in the form of small case series and cohort studies with mixed results. 

A systematic review of the literature showed that treatment studies (using transvenous catheter embolization, surgical ligation, hysterectomy, or hormonal suppression) found improvement from 24% to 100%; a similarly wide range of improvement was found with change in continuous rating of visual analogue scale pain scores. 
The optimal diagnostic approach for PCS-related pelvic pain remains unclear, and controlled trials comparing medical and interventional treatments are urgently needed for PCS-associated pelvic pain. 

Additional well-designed randomized controlled trials are needed to evaluate the safety and effectiveness of embolization therapy as a treatment for PCS. 

The procedure 37241 x 1, closing of blood vessels in the pelvis is not considered more beneficial for this patient's diagnosis. 

1. The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. 
2. The outpatient procedure 37241 x 1, closing of blood vessels in the pelvis does not need approval from the appropriate regulatory bodies for this diagnosis. 
3. Due to lack of scientific evidence of health improvement, it is unknown if this patient is a good candidate for outpatient procedure 37241 x 1, closing of blood vessels in the pelvis. 
4. The outpatient procedure 37241 x 1, closing of blood vessels in the pelvis is not the best available treatment for this patient at this time. 
5. The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. 
6. The adverse risks are increased over standard treatment/services. 

The carrier's denial of coverage for outpatient procedure 37241 x 1, closing of blood vessels in the pelvis should be upheld.