Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Pelvic Congestion Syndrome. 
Treatment: Ovarian and internal iliac vein embolization. 
The insurer denied coverage for ovarian and internal iliac vein embolization. 
The denial is upheld. 

The patient is diagnosed with pelvic congestion syndrome (PCS). Pelvic vein/ovarian vein embolization is planned. 

All available medical documentation was reviewed. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. The articles submitted by the treating physician and the available literature evidence references supports improvement in outcomes in patients who are appropriately selected for the therapy planned procedure. 

Brown, C. L., Rizer, M., Alexander, R., Sharpe, E. E., 3rd, & Rochon, P. J. (2018), "PCS consists of clinical symptoms with concomitant anatomic and physiologic abnormalities originating in venous insufficiency. The etiology of PCS is diverse involving both mechanical and hormonal factors contributing to venous dilatation (>5 millimeters (mm)) and insufficiency. Factors affecting the diagnosis of PCS include variance of causes and clinical presentations of pelvic pain and relatively low sensitivity of noninvasive diagnostic imaging and laparoscopy to identify insufficiency compared with catheter venogram." 

Venbrux, A. C., Chang, A. H., Kim, H. S., Montague, B. J., Hebert, J. B., Arepally, A., Rowe, P. C., Barron, D. F., Lambert, D., & Robinson, J. C. (2002), "For patients with ovarian/internal iliac varices, transcatheter embolotherapy provides a nonsurgical treatment option. There is a significant decrease in pain based on VAS without any notable impact on menstrual cycle." 

Ovarian and internal iliac vein embolization have final approval from the appropriate regulatory bodies for this diagnosis. They are recognized procedures; use Food and Drug Administration (FDA) - approved equipment and are reimbursable based on Centers for Medicare and Medicaid Services (CMS) guidelines. 

This patient is not a good candidate for ovarian and internal iliac vein embolization. 

There was essentially no clinical information provided. Only the diagnosis was provided. Based on the available literature evidence, this procedure is reserved for patients who have failed pharmacological therapy (progestins, GnRH - active medications); also, the dilatation of pelvic vasculature should be proven radiographically. Provided medical records do not support that the patient is a good candidate for ovarian and internal iliac vein embolization. 

Based on the available literature evidence, this procedure is reserved for patients who have failed pharmacological therapy (progestins, GnRH - active medications); also, the dilatation of pelvic vasculature should be proven radiographically. As this information was not provided, it cannot be confirmed that ovarian and internal iliac vein embolization is the best available treatment for this patient at this time. 

There is increased risk of pelvic tissue necrosis/ischemia and worsening of stasis. 

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. 

Based on the lack of clinical information provided, available literature evidence does not support the embolization procedure at this point for this patient; it also does not support the likelihood of the procedure to be more beneficial than any of the standard treatments / procedures for this patient. 

In summary, the denial of ovarian and internal iliac vein embolization 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.