Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic congestion syndrome. 

Treatment: Outpatient procedure 37241 x 1, closing of blood vessels in the pelvis. 

The insurer denied coverage for outpatient procedure 37241 x 1, closing of blood vessels in the pelvis. 

The denial is overturned. 

This is a female patient with a history of pelvic congestion syndrome (PCS), varicose veins, and thrombophlebitis.  She presented to the vascular surgeon's office for the re-evaluation of lower extremity varicose veins and pelvic pain.  There was a large amount of varicose veins in both lower extremities.  The patient stated that she had laparoscopic surgery by the Gynecologist and was found to have a large right ovarian vein.  The treating practitioner recommended obtaining a computed tomography (CT) venogram of the abdomen and pelvis to reassess PCS.  Imaging was done and the physician recommended ovarian vein embolization (OVE) to treat PCS. 

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.  Gonadal (ovarian) vein embolization has been shown to be a viable minimally invasive endovascular treatment options for patients with pelvic congestion syndrome and evidence of venous reflux disease in the gonadal veins.  The patient in question has documented evidence of pelvic congestion syndrome on non-invasive imaging, clinical history, and physical examination.  She would be a good candidate for gonadal vein embolization. 

The outpatient procedure 37241 x 1, closing of blood vessels in the pelvis does have final approval from the appropriate regulatory bodies for this diagnosis.  The Society of Interventional Radiology and British Society of Interventional Radiology recommends gonadal vein embolization as a minimally invasive endovascular treatment option for patients with pelvic congestion syndrome. 

This patient is a good candidate for outpatient procedure 37241 x 1, closing of blood vessels in the pelvis.  The patient has documented evidence of pelvic congestion syndrome on non-invasive imaging, clinical history, and physical examination.  She would be a good candidate for gonadal vein embolization and would be expected to have a clinically efficacious outcome from the procedure. 

The outpatient procedure 37241 x 1, closing of blood vessels in the pelvis, is the best available treatment for this patient at this time.  Gonadal (ovarian) vein embolization has been shown to be a viable minimally invasive endovascular treatment option for patients with pelvic congestion syndrome and evidence of venous reflux disease in the gonadal veins.  The patient has documented evidence of pelvic congestion syndrome on non-invasive imaging, clinical history, and physical examination.  The patient would be a good candidate for gonadal vein embolization and would be expected to have a clinically efficacious outcome from the procedure. 

The adverse risks of gonadal (ovarian) vein embolization are damage to selected blood vessels, bleeding, infection, venous thrombosis, and contrast-induced nephropathy.  However, the overall risk profile for gonadal vein embolization is much less when compared to traditional open vascular surgery. 

The requested procedure is likely to be more beneficial than any other standard service. 

The carrier's denial of coverage for outpatient procedure 37241 x 1, closing of blood vessels in the pelvis should be overturned.