Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Pelvic congestion syndrome.

Treatment: outpatient surgery (37241 x 1).

The insurer denied coverage for outpatient surgery (37241 x 1).

The denial is upheld.

The patient is an adult with chronic pelvic congestive syndrome (PCS) recommended treatment with a pelvic venogram, coil embolization of the ovarian vein and sclerotherapy of pelvic varices under fluoroscopic guidance. The request is for ovarian vein embolization, which is under review.

All available medical documentation was reviewed.

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

There is no data from well conducted prospective studies to show that this procedure improves outcomes in patients with congestive pelvic syndrome. This procedure is not supported by peer-reviewed data, it is not standard of care, and it is not supported by professional organizations.

Saadat Cheema, O., &amp; Singh, P. (2022), "Medical management should be the first-line treatment for PCS. This is due to decreased complications of medical management as compared to invasive procedures. Gonadotropin-releasing hormone agonists, danazol, combined oral contraceptives, progestins, phlebotonics, and non-steroidal anti-inflammatory drugs are a few treatment options that have shown effective management for the pain in PCS. "

Alonso-Arroyo, V., et al. (2021), "A diagnostic and therapeutic phlebography allowed a selective catheterization of a group of pelvic varicose veins draining to the left ovarian and to the internal iliac veins. There were no complications during the procedure and the symptoms disappeared 2 days later. Circumaortic left renal vein may cause hematuria, proteinuria, pelvic congestion syndrome, and massive hemorrhage during surgery. A conservative treatment is recommended for patients without gynecourological/renal symptoms or with mild hematuria. The endovascular treatment by gonadal venous embolization is safe and effective."

O'Brien, M. T., &amp; Gillespie, D. L. (2015), "Our MEDLINE search revealed more than 3756 references to chronic pelvic pain. Specific references to PCS, pelvic chronic pain, ovarian vein reflux, nutcracker syndrome, renal vein obstruction, pelvic varicosities, labial varicosities, embolization, treatment, and therapies, however, included only 260 references. Thirty-seven references were small series including fewer than 50 patients or individual case reports documenting medical, surgical, or endovascular treatment of PCS. The majority of these papers demonstrated successful treatment of symptoms from PCS with embolization of one or both ovarian veins in addition to treatment of refluxing internal iliac vein branches. In addition, open surgery and, more recently, endovascular stenting of left renal vein (LRV) obstruction have shown some promise in alleviating symptoms attributed to nutcracker syndrome."

Outpatient surgery (37241 x 1) does not have final approval from the appropriate regulatory bodies for this diagnosis. 

This patient is not a good candidate for outpatient surgery (37241 x 1).

Outpatient surgery (37241 x 1) is not the best available treatment for this patient at this time. Use of physical therapy would be the most appropriate first course of therapy in this setting. 

The long-term safety of the recommended course of therapy has not been established. 

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

In summary, the denial of outpatient surgery (37241 x 1) 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.