Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pelvic congestion

Treatment: vascular embolization or occlusion

The insurer denied coverage for vascular embolization or occlusion

The denial is overturned


 
This case involves an adult female with a history of significant pelvic pain, uterine bleeding, pelvic cramping, aching, heaviness, and bloated feeling along with significant dyspareunia and hemorrhoids who was noted to have prominent dilated pelvic veins on recent diagnostic laparoscopy.  The physician stated the patient was likely to have pelvic venous disease with possibly non-thrombotic iliac vein lesion and/or nutcracker phenomenon.  A computed tomography (CT) venogram was ordered and reviewed.  The report demonstrated significant dilated Renal and parametrial veins consistent with pelvic venous disease.  The left inferior ovarian vein was markedly dilated leading into the parametrial veins along with the right ovarian vein noted to be mildly dilated as well.  There was significant compression of the left common iliac vein by the right common iliac artery consistent with non-thrombotic iliac vein lesion, which also was a significant trigger to the pathophysiology.  

Medical literature has noted that pelvic congestion syndrome (PCS) is a misunderstood and often underdiagnosed cause of chronic pelvic pain (CPP) in women of child-bearing age.  Symptoms of this condition can include pelvic pain lasting only 6 months, usually described as a dull ache or heaviness in the lower abdominal/pelvic region, presence of visible or nonvisible pelvic varices, dysmenorrhea, dyspareunia, bladder irritability and/or urgency, worsening of symptoms after prolonged periods of standing, lower extremity varices, and back pain and/or leg pain.  Some of the differential diagnoses include pelvic inflammatory disease, endometriosis, interstitial cystitis, adhesions, malignancy, adenomyosis, irritable bowel disease, and uterine fibroids.  Medical management of pelvic congestion syndrome is an option for treatment with use of drugs such as medroxyprogesterone acetate (MPA) and gonadotropin-releasing hormone (HnRH)].  However, the use of those drugs is not a long-term method due to the high reports of symptom recurrence after 6 months, possibility of adverse events, and the inability to reduce symptoms caused by secondary PCS.  There are several traditional and laparoscopic surgical options with reported success in the management of PCS symptoms, which often involve the removal of uninvolved bystander structures and the risk of surgical complications and possible fertility issues, which is why endovascular treatment has been the most agreed-upon treatment for PCS.  Transcatheter embolization is a safe and reliable treatment modality for PCS that may conveniently be performed at the same time as diagnostic venography.  Complications with embolization are not common, but can include coil migration, vessel perforation, local phlebitis, deep vein thrombosis, occlusion of nontarget vessels, and reaction to a contrast agent.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for vascular embolization or occlusion (surgical procedure to decrease the flow of blood to specific veins in the body) is substantiated.