Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Symptomatic varicocele.

Treatment: Coil embolization (vascular embolization or occlusion code 37241).

The insurer denied coverage for coil embolization (vascular embolization or occlusion code 37241).

The denial is overturned. 

This is a male patient with chronic symptomatic left-sided varicocele.  A testicular sonogram was strongly positive for left-sided varicocele.  The patient opted for endovenous varicocele embolization.  The patient's insurance carrier denied coverage for the procedure, claiming that this procedure was experimental or investigational.

A varicocele is caused by an abnormal dilatation of the pampiniform venous plexus within the testicle, resulting in reflux of blood through incompetent gonadal vein valves in males.  This is a common abnormality found in 5-17% of males, favoring the left testicle, and typically causes pain, swelling, discomfort, infertility, and gonadal hypoplasia.  The etiology of varicocele is unclear.  The diagnosis of varicocele is usually clinical.  The patient presents with a palpable scrotal abnormality that increases in size with Valsalva maneuver and diminishes in the supine position.  Ultrasound is the preferred imaging modality when subclinical varicocele is suspected.  The finding is a dilated pampiniform complex with 2 millimeter (mm) dilatation being the upper limit of normal.  Reflux may be noted with Valsalva maneuver using Doppler or color flow imaging.  There is no effective medical treatment for varicoceles.  The goal of therapy is to interrupt internal spermatic vein in order to prevent retrograde flow of blood into the scrotum.  Surgical or laparoscopic ligation of the internal spermatic vein can be performed at multiple anatomic levels.  The recurrence rate is approximately 10-20% following surgical ligation, usually due to collateral flow around a ligature, a missed additional internal spermatic vein, or loose ligature.  Percutaneous embolization of the internal spermatic vein with coils is the preferred nonsurgical technique.  Percutaneous embolization allows for multiple internal spermatic veins to be individually identified and embolized during one session.  The results of embolization of internal spermatic veins are similar to surgery, with a technical success rate that exceeds 90% and a recurrence rate that approaches 10%.  Overwhelming data from over 30 years of experience suggests that percutaneous embolization for varicocele is a safe procedure in both the adult and pediatric patients.  Embolization offers certain advantages over surgery, such as the ability to perform venography and the use of local anesthesia in lieu of more invasive and anesthetic technique.  With careful patient selection, and pretreatment counseling, embolization can be appropriately employed as a safe and effective treatment option for symptomatic varicocele.

Vascular embolization procedure is a component of the standard of care in treating varicoceles and will continue to gain favor in the future.  The scientific evidence in the peer-reviewed literature supports the efficacy of this procedure.  It is a widely accepted interventional procedure in the hospitals and outpatient centers in the United States and is recognized by the government boards, including the American Board of Radiology (ABR) and American College of Radiology (ACR).  The procedure meets the standard for the best nonsurgical treatment option for this patient at this time and offers more benefits as a minimally invasive procedure than surgical varicocelectomy for this particular patient.

The coil embolization (vascular embolization or occlusion code 37241) is likely to be more beneficial than any of the standard treatments/procedures for this patient

The carrier's denial of coverage for a coil embolization (vascular embolization or occlusion code 37241) should be overturned.