Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #1:

Diagnosis: Chronic pelvic pain.

Treatment: vein embolization (procedure code 37241).

The insurer denied coverage for vein embolization (procedure code 37241).

The denial is upheld.

The patient presented with complaints of varicose veins in bilateral legs and vagina. She had sclerotherapy labial varicosities after her second baby. The injections made the pain tolerable, but the varicosities came back after the third baby. She has vaginal pressure, pain, soreness, difficulty walking and fatigue, and throbbing in bilateral legs. She complains of dyspareunia, pelvic pressure, leg achiness, heaviness, tiredness, itching, and swelling all day. She is 3 months postpartum and does not plan on any additional pregnancies. She plans to breastfeed for another year. She has a history of Sjogren's and Idiopathic Thrombocytopenic Purpura (ITP). Examination found bilateral thigh, calf, right labial, bilateral groin varicosities, and right corona phlebectatica. Assessment is pelvic varices, labial varicosities, varicose veins of bilateral lower extremities, chronic venous insufficiency, dyspareunia, chronic pelvic pain, and pressure. 

A venous ultrasound found no deep vein thrombosis (DVT), and no pelvic outflow obstruction. 
A computed tomography (CT) venogram showed no venous thrombosis or compression within the abdomen or pelvis. The cause of pelvic pain is unclear based on the exam. Negative for May-Thurner syndrome. Anteverted uterus noted. 

Evidence-based literature notes that "patients with pelvic vein disease, ovarian and/or internal iliac vein embolization demonstrate excellent technical and clinical success rates with relatively low complication rates and should be considered as standard management, in conjunction with medical therapy. However, further research is needed to identify additional predictors of successful outcomes after embolization therapy.  A well-designed randomized controlled trial is needed to assess trans-venous occlusion in an unbiased fashion to definitively determine the clinical success."

The review of the literature and clinical found the procedure, of vein embolization for pelvic congestion is not the current standard of care.

The scientific evidence reviewed notes the need for additional studies. 

Vein embolization devices have a 510k approval; however, there was no evidence of final approval found. 

This patient may be a good candidate for vein embolization, however, the CT venogram did not find evidence of venous thrombosis or compression within the abdomen or pelvis. An anteverted uterus was noted.  The cause of pelvic pain is unclear based on the exam, although the provider noted left ovarian vein is 10.1 and 13.4 millimeters (mm). 

There are several treatment options for pelvic congestion syndrome. Hormonal medications can reduce blood flow and congestion of the varicose veins. If these are ineffective, then minimally invasive therapies may be considered such as nonsurgical embolization (intentional plugging) of the varicose veins. 

The following risks are increased over standard treatment/services. A small number of women develop infections after embolization. Since the procedure involves placing a tube inside blood vessels, it may damage them or cause bruising and bleeding at the point of incision. There's a 10 % chance that the varices may develop in the veins again. It exposes the ovaries to radiation.

The record does not indicate if any hormonal medications were attempted. Should the symptoms continue after exhausting standard treatment therapies, then this procedure may be beneficial. 

In summary, the denial of Vein Embolization (procedure code 37241) and coverage for the requested service/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.