Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #3

The patient is a female with a well-documented history of pelvic pain, and pain with sexual intercourse (dyspareunia).  Imaging studies including a computed tomography (CT) venogram and a catheter based venogram have confirmed origin of the symptoms to be associated with dilated refluxing pelvic veins.  Venous embolization of these veins is recommended and has been denied by the insurer this treatment is under review for medical necessity.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.  According to Glovickzki, et al. (2011), in a multi-society endorsed expert consensus evidence based guideline built upon a broad review of published literature and published in the most prestigious journal in the field, "We suggest treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs, or transcatheter sclerotherapy, used alone or together." This procedure is backed a by a broad consensus of published literature and by practicing vascular specialists in the field throughout the country. Per O'Brien, and Gillespie (2014), "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."

Per Koo and Fan. (2014), "Pelvic venous insufficiency (PVI), defined as retrograde flow in the gonadal and internal iliac veins, is the underlying cause of pelvic congestion syndrome (PCS), a common cause of disabling chronic pelvic pain in women of child-bearing age. PCS is a chronic pain syndrome characterized by positional pelvic pain that is worse in the upright position and is associated with pelvic and vulvar varicosities as well as symptoms of dyspareunia and postcoital pain.  Through collaterals to the lower extremity venous system, PVI may also contribute to varicose vein formation and recurrence in the lower extremities. Endovascular embolization of the ovarian and internal iliac veins has become the treatment of choice for PVI and PCS."

Per Brown, et al. (2018), "Percutaneous embolization for PCS is an effective method of treatment having a high percentage of symptom improvement (reported in 697 of 762 patients)." Per Mahmoud O. et al. (2016), "The immediate success rate for the endovascular treatment of PCS is good and the complication rate low."  The Society for Vascular Surgery and the American Venous Forum have endorsed this procedure as reflected in the guidelines published by Glovickzki.  Therefore, the patient is as a good candidate for the procedure, vein embolization for pelvic congestion syndrome.

This procedure is backed a by a broad consensus of published literature and by practicing vascular specialists in the field throughout the country.  Therefore, vein embolization for pelvic congestion syndrome is the best available treatment for this patient at this time.  The procedure is likely to be more beneficial than other procedures, as there are really no other procedures available to treat the condition.  This procedure is regarded as the standard treatment/procedure for this patient.  
                                                  
The carrier's denial of coverage for vein embolization for pelvic congestion syndrome should be reversed.