Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic congestion syndrome. 
Treatment: Code 37241 - ovarian vein embolization. 
The insurer denied coverage for code 37241 - ovarian vein embolization. 
The denial is overturned. 

The patient has been diagnosed with pelvic congestion syndrome (PCS). The patient has a history of pelvic pain exacerbated by exercise, menstruation, standing, and intercourse. The patient has had imaging workup total ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) that showed prominent bilateral adnexal vessels with ovarian vein reflux. The patient underwent bilateral renal vein embolization to treat bilateral gonadal vein insufficiency localized to the anatomic location of her venous varices on the pre-procedure MRI imaging findings. The procedure was noted as successful in occluding the gonadal veins. The patient presented for follow-up with complaints of pelvic congestive pain. The patient reported that since their last visit symptoms did improve for about 2 months, but the patient reported for the last few weeks  their pain has been worse again in the left pelvic area. The patient reported symptoms that required daily over-the-counter (OTC) pain medication and reports still having heaviness bloating and pain. The pain is more manageable but definitely still there and limiting their daily activities with less. The patient reported that since the last visit there was left-sided pelvic pain and discomfort during intercourse. The MRI of the pelvis showed no acute pelvic findings with occasional artifact, normal appearance of ureters and ovaries and interval decrease in mild likely physiological free fluid in the pelvis. The magnetic resonance angiography (MRA) of the pelvis showed impression of normal appearance of the arterial and venous structures of the pelvis and visualized abdomen. The previously described prominence of the left gonadal vein and peri-uterine vein structure is not appreciated in the current study. 

Per the cited reference, ovarian and pelvic vein embolization, as well as endovascular stenting of common iliac vein compression, should be considered as management options for pelvic venous disorders (PeVD). Both treatments have been shown to be safe and effective for patients with chronic pelvic pain (CPP) of venous origin, regardless of age (Knuttinen, et al., 2023). 

The code 37241 - Ovarian Vein Embolization (treatment for pelvic congestion syndrome) has final approval from the appropriate regulatory bodies for this diagnosis. 
Based the symptomology and imaging finding for bilateral gonadal vein insufficiency,
this patient is a good candidate for code 37241 - Ovarian Vein Embolization (treatment for pelvic congestion syndrome. 

Ovarian Vein Embolization (treatment for pelvic congestion syndrome) is the best available treatment for this patient at this time. 

Per the cited reference, major complications are rare with ovarian venous embolization. According to recent studies, there are no greater adverse risks increased over standard treatment/services for the treatment of pelvic congestion syndrome (Joh, et al., 2021). 
Scientific evidence in peer-reviewed literature supports ovarian vein embolization for the treatment of pelvic congestion syndrome and has  final approval from the appropriate regulatory bodies for this diagnosis. 

In summary, the denial of code 37241 - Ovarian Vein Embolization (treatment for pelvic congestion syndrome) and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.