Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #2:

Diagnosis: Chronic pelvic pain.

Treatment: vein embolization (procedure code 37241).

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

The denial is upheld.

This is an adult female who has been evaluated for treatment of PCS (Pelvic Congestion Syndrome).

The request for Vein Embolization (procedure code 37241) is under review.

The insurer has denied coverage for vein embolization (procedure code 37241). In their Final Adverse Determination letter, they write that the appeal for coverage of vein embolization is investigational. The records show that the patient has long-term pelvic pain. The procedure is investigational. There has not been enough research to prove it will work for the patient.

The computed tomography (CT) shows no venous anomalies.

There is insufficient medical literature to support the request for Vein Embolization (procedure code 37241) for this patient's indication. At this time, additional research is needed. Therefore, the scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes.

Basile, A., Failla, G., & Gozzo, C. (2021), "Pelvic congestion syndrome (PCS) is often an underdiagnosed cause of chronic pelvic pain in female patients with radiology detection of gonadal vein dilatation and parauterine varices. It may occur either alone or in combination with vulvar varicosities and/or lower extremity venous insufficiency. Although transcatheter venography represents the gold standard for PCS diagnosis, it is performed after inconclusive noninvasive imaging such as Doppler Ultrasound, computed tomography (CT) scan, and magnetic resonance imaging (MRI). Once diagnosis has been confirmed, management of PCS includes medical, surgical, and endovascular therapy. Medical and surgical treatments are less effective than transcatheter pelvic vein embolization. The 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."

The vein embolization (procedure code 37241) does have final approval from the appropriate regulatory bodies but not specifically for PCS.     

This patient is not a good candidate for vein embolization (procedure code 37241). This is an unproven process. In addition, a computed tomography (CT) scan documented no venous anomalies.     

The vein embolization (procedure code 37241) is not the best available treatment for this patient at this time.     

There are always some risks associated with any invasive endovenous procedure.     

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

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.