Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic congestion syndrome. 
Treatment: Code 37241 - ovarian vein embolization. 
The insurer denied coverage for code 37241 - ovarian vein embolization. 
The denial is upheld. 

According to the medical records, this is a patient who has been evaluated and treated for Pelvic Congestion Syndrome (PCS). This patient is being considered for retreatment for recurrent symptoms. 

The insurer has denied coverage for code 37241 - Ovarian Vein Embolization (treatment for pelvic congestion syndrome). In their Final Adverse Determination letter, the insurer writes that they completed the review and determined that the adverse determination should be upheld. Based upon the criteria and the lack of peer reviewed literature, endovascular occlusion of the ovarian and/or internal veins has not been medically proven to be effective. 

The patient's provider is appealing the decision. In an appeal letter, the provider writes that the patient does not have a gynecologic problem, that the patient has a vascular problem and so ought to be considered and treated by vascular experts. The patient underwent bilateral gonadal vein embolization to treat bilateral gonadal vein insufficiency. The letter also stated that the treatment was appropriate based on the patient's presenting symptoms of intermittent acute pain localized to the anatomic location of the venous varices on the pre-procedural magnetic resonance imaging (MRI) imaging and the  findings of the MRI. The treatment was successful in occluding the markedly incompetent gonadal veins. 

The peer-reviewed literature does not support a result of improvement in health outcome. 

This patient was previously treated for Pelvic Congestion Syndrome which failed to permanently treat their symptoms. 

"Pelvic congestion syndrome (PCS) is often an underdiagnosed cause of chronic pelvic pain in female patients with radiology detection of gonadal vein dilatation and periuterine varices. It may occur either alone or in combination with vulvar varicosities and/or lower extremity venous insufficiency. Although transcatheter venography represent the gold standard for PCS diagnosis, it is performed after inconclusive noninvasive imaging such as Doppler Ultrasound, computed tomography (CT) scan, and MRI. Once the diagnosis has been confirmed, management of PCS includes medical, surgical, and endovascular therapy. Medical and surgical treatments have been shown to be less effective than transcatheter pelvic vein embolization. This latter has been proven to be a safe, effective, and durable therapy for the treatment of PCS. Numerous studies have shown their results in PCS endovascular treatment, but neither of them has been subjected to an adequate randomized controlled trial. A well-designed randomized controlled trial is urgently needed to assess transcatheter embolization clinical success" (Basile, A., Failla, G., & Gozzo, C. 2021). 

"The immediate success rate for the endovascular treatment of PCS is good and the complication rate low. Most patients report relief in the symptoms for up to 5 years after the procedure. However, there are no randomized or high-quality controlled trials and the level of evidence therefore remains at C" (Mahmoud, O. et al. 2016). 

In summary, the denial of code 37241 - Ovarian Vein Embolization (treatment for pelvic congestion syndrome) 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.