Modifiedblue cross blue shield - louisianaPolicy 00691

Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele

This policy describes the payer's coverage stance on endovascular embolization (occlusion) of ovarian, internal iliac, and testicular (spermatic) veins for treatment of pelvic congestion syndrome and varicocele for members of Blue Cross and Blue Shield of Louisiana.

Policy Summary

Payerblue cross blue shield - louisiana

PolicyVein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele

Policy CodePolicy 00691

Change TypeTitle change and addition of investigational statement

Effective Date02/01/2020

Next Review Date11/20/2026

Key ActionObtain prior review for endovascular occlusion procedures, as these are considered investigational and require pre-coverage determination.

SourceLink

POLICY UPDATE CHANGES

Title changed from 'Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome' to 'Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele'.

An investigational statement was added to the policy.

Current effective date updated to 02/01/2026.

Coding update scheduled for 07/01/2025.

Investigationalovarian/internal iliac vein embolization for pelvic congestion syndrome

Investigationaltesticular (spermatic) vein embolization for varicocele

63.7%–100%

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

reported clinical success rates

3505total individuals in varicocele review

≥7clinical trials referenced

02/01/2026Current effective date

Coverage Criteria and Policy Stance

Investigational indications

Coverage stance and evidence summary

Investigational determinations: Endovascular occlusion (embolization, sclerotherapy) of the ovarian and/or internal iliac veins for pelvic congestion syndrome is considered investigational; endovascular embolization of the testicular (spermatic) vein for varicocele is considered investigational.

Policy labels both indications investigational based on available evidence.

Pelvic congestion syndrome - guideline-backed options

Guideline-based treatment suggestions for pelvic congestion syndrome

Guideline recommendations: Suggest treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs, or transcatheter sclerotherapy, used alone or together (grade 2B: weak recommendation, moderate quality of evidence).

From 2011 guideline; medical management not included among recommendations; pharmacologic agents may offer short-term relief but long-term effectiveness unproven.

Surgical alternative: If less invasive treatment is not available or has failed, suggest surgical ligation and excision of ovarian veins to treat reflux (grade 2B: weak recommendation, moderate quality of evidence).

From 2011 guideline.

Varicocele - indications and contraindications

Guidance related to varicocele treatment (AUA/ASRM)

Indication for surgical varicocelectomy: Consider surgical varicocelectomy in men attempting to conceive who have palpable varicocele(s), infertility, and abnormal semen parameters (moderate recommendation, Grade B).

AUA/ASRM 2020 guideline part II.

Not recommended: Do not recommend varicocelectomy for men with nonpalpable varicoceles detected solely by imaging (strong recommendation, Grade C).

AUA/ASRM guidance.

Investigational — Policy-level coverage stance and investigational criteria

Policy-level coverage stance and investigational criteria

Investigational statement: Vein embolization for pelvic congestion syndrome and varicocele is addressed with an investigational statement in this policy; investigational determinations are based on FDA marketing status and the need for further studies or peer-reviewed evidence.

Investigational definition and criteria are provided in policy.

Based on review of available data, endovascular occlusion (embolization or sclerotherapy) of the ovarian and/or internal iliac veins for pelvic congestion syndrome is considered investigational. Similarly, endovascular embolization of the testicular (spermatic) vein for varicocele is considered investigational. Coverage is not available for investigational medical treatments, procedures, drugs, devices, or biological products.

There is no Medicare national coverage determination (NCD) for vein embolization in the treatment of pelvic congestion syndrome or varicocele. In the absence of an NCD, coverage decisions are left to the discretion of local Medicare carriers and local carrier requirements may affect coverage determinations.

Federal and state law, together with the specific terms of a member’s contract (including definitions and any exclusions), take precedence over this Medical Policy. Contract language or applicable law that differs from the policy may govern coverage and should be considered first when determining eligibility.

Guideline guidance notes that pharmacologic agents to suppress ovarian function (e.g., medroxyprogesterone or gonadotropin-releasing hormone analogues) may provide short-term pain relief for pelvic congestion syndrome, but their long-term effectiveness has not been proven. Medical management is not included among the procedural recommendations in the cited guideline.

Per this policy’s definition, interventions designated as Investigational are those whose effectiveness has not been clearly established or incorporated into standard medical practice. Such investigational treatments are considered not established as effective and therefore are generally not covered, subject to applicable contract terms and law.

Codes and Coding Notes

Referenced device/product codesmixed

FDA product code KRD

Embolization devices (coils, plugs) cleared for peripheral arterial/venous embolization

Referenced drug approvalsmixed

ANDA 040541

Sotradecol (sodium tetradecyl sulfate) approval for small uncomplicated varicose veins

Coding updatesmixed

No codes listed

Codes used to identify services associated with this policyCPT

36011	CPT code listed in policy
36012	CPT code listed in policy
37241	CPT code listed in policy
75894	CPT code listed in policy

HCPCSHCPCS

No codes listed

ICD-10 Diagnosis CodesICD-10

I86.1	ICD-10 diagnosis code listed in policy
I86.2	ICD-10 diagnosis code listed in policy
I86.3	ICD-10 diagnosis code listed in policy
I87.2	ICD-10 diagnosis code listed in policy
N94.89	ICD-10 diagnosis code listed in policy
R10.20	ICD-10 diagnosis code listed in policy
R10.21	ICD-10 diagnosis code listed in policy
R10.22	ICD-10 diagnosis code listed in policy
R10.23	ICD-10 diagnosis code listed in policy
R10.24	ICD-10 diagnosis code listed in policy

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required / Investigational Procedures

Coverage is not available for investigational treatments or procedures. Based on review of available data, endovascular occlusion of the ovarian vein and/or internal iliac veins for pelvic congestion syndrome and endovascular embolization of the testicular (spermatic) vein for varicocele are considered investigational and would require prior review and are not covered under this policy.

Investigational procedures: embolization/occlusion of ovarian, internal iliac, and testicular (spermatic) veins
Prior authorization: Verify with payer before scheduling — investigational procedures may require prior review or be denied

Billing Rule

Verify Coding / Prior Authorization

Verify current coding and prior authorization requirements with the payer prior to performing or billing for services associated with this policy. Coding for services potentially associated with this policy has been updated (see policy history) and listed CPT and ICD-10 codes may be used for claims reporting; confirm any plan-specific PA rules or code changes before submission.

Background and Definitions

Pelvic congestion syndrome is characterized by chronic pelvic pain that is often aggravated by standing and is associated with pelvic venous varices. Diagnostic criteria are not well defined and the condition is typically considered a diagnosis of exclusion. Initial management is commonly conservative, including analgesics and consideration of medical therapies; endovascular occlusion has been proposed as an alternative to surgery but the policy labels ovarian/internal iliac vein embolization as investigational based on available evidence. Guideline literature has suggested coil embolization, plugs, or transcatheter sclerotherapy as potential treatments (grade 2B: weak recommendation, moderate-quality evidence), while also noting that pharmacologic suppression of ovarian function may offer only short-term relief.

Pelvic congestion syndrome / pelvic venous disorder — definition and key features

DefinitionChronic pelvic pain syndrome associated with pelvic venous varices and congestion; often aggravated by standing, may include dyspareunia, postcoital ache, and tenderness over the ovarian point; considered a diagnosis of exclusion with nonspecific diagnostic criteria.

Typical patient populationUsually occurs before menopause and pain is often worse before or during menses.

Associated featuresSymptoms suggestive of venous origin (postcoital ache, ovarian point tenderness) and pelvic vascular varices leading to vascular congestion.

Policy Summary

Payerblue cross blue shield - louisiana

PolicyVein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele

Policy CodePolicy 00691

Change TypeTitle change and addition of investigational statement

Effective Date02/01/2020

Next Review Date11/20/2026

Key ActionObtain prior review for endovascular occlusion procedures, as these are considered investigational and require pre-coverage determination.

SourceLink

On This Page

Codes that may be associated with this policy: CPT 36011, 36012, 37241, 75894; ICD-10 I86.1, I86.2, I86.3, I87.2, N94.89, R10.20-R10.24
Coding update recorded: 07/01/2025 — verify any subsequent updates

Billing Rule

Coding and Prior Authorization May Apply

Services associated with this policy may include the CPT and ICD-10 codes listed in the coding section. Claims and reporting should follow CPT guidance and payer-specific billing instructions. Confirm whether prior authorization applies for the specific product/line of business before providing services.

Follow CPT descriptive terms and current code set when reporting services
Confirm PA requirements with the member's benefit contract and payer rules

Documentation Required

Conservative Therapy Preferred Initially

An initial conservative approach to pelvic congestion syndrome and most varicoceles is preferred. Conservative management for pelvic congestion syndrome may include analgesics (short-term NSAIDs), hormonal therapy (eg, medroxyprogesterone, goserelin, etonogestrel) with or without psychotherapy. Most varicoceles do not require intervention; treatment is generally reserved for specific clinical scenarios (eg, pain, infertility, testicular atrophy). Document prior conservative treatments and their duration when submitting requests.

Document prior conservative therapy: medications, duration, response (eg, NSAIDs, hormonal therapy, psychotherapy)
For varicocele, document symptoms/indications: palpable varicocele, pain, infertility, or testicular atrophy

Documentation Required