Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Pelvic Pain

Treatment: procedure code 37241, vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, and varicoceles) to treat R10.2 pelvic and perineal pain.

The insurer denied coverage for procedure code 37241, vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, and varicoceles) to treat R10.2 pelvic and perineal pain.

The denial is upheld.

The patient is a female with a history of migraines, endometriosis, and complex pelvic pain status post left ovarian vein embolization with reported improvement in pelvic pain. She presented to the Interventional Radiology (IR) department with a history of recurrent pelvic pain. The magnetic resonance imaging (MRI) study showed recanalized refluxing left ovarian vein and a dilated right ovarian vein. The treating provider wishes to perform ovarian vein embolization which plan is denying as not medically necessary. The requested service is denied based on the medical policy Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome.

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

There is a lack of peer-reviewed literature that supports a superior outcome with ovarian and iliac vein embolization for pelvic congestion syndrome compared with other standard medical treatments for this condition. The presence of abnormal refluxing ovarian veins on MRI does not, in and of itself, indicate that ovarian vein embolization is the appropriate treatment for the patient's pelvic pain. There is a lack of peer-reviewed literature supporting a better clinical outcome with the embolization procedure verses standard medical treatment which would include physical therapy, compression garments, hormonal therapy, and others.

Up to Date notes that "Pelvic congestion syndrome (PCS) is characterized by chronic pelvic discomfort exacerbated by prolonged standing and coitus in women who have periovarian varicosities on imaging studies. The etiology of PCS is unclear, and the optimum treatment is uncertain. Development of an evidence-based approach to managing these patients has been limited by the absence of definitive diagnostic criteria." They also state "Although the absence of pelvic venous changes helps to exclude PCS, the presence of these abnormalities is not diagnostic, as incompetent and dilated ovarian veins are common, nonspecific findings."

The 37241 code is an approved CPT code for embolization of varicoceles and incompetent ovarian/iliac veins and gastric varices and venous vascular malformations and lymphatic malformations and embolization of patent perforating veins affecting dialysis fistula function.     

This patient is not a good candidate for procedure code 37241. The patient has many possible sources for her pelvic pain and has recurrence of her pain despite a technically successful embolization procedure. The presence of abnormal refluxing ovarian veins on MRI does not, in and of itself, indicate that ovarian vein embolization is the appropriate treatment for the patient's pelvic pain. There is a lack of peer-reviewed literature supporting a better clinical outcome with the embolization procedure verses standard medical treatment which would include physical therapy, compression garments, hormonal therapy, and others.     

There is no peer-approved literature that supports ovarian vein embolization (CPT code 27241) as the best available treatment for the patient's pelvic pain at this time. The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.                                                       

The carrier's denial of procedure code 37241, vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, and varicoceles) to treat R10.2 pelvic and perineal pain should be upheld.