CurrentBlue Cross Blue Shield - MassachusettsPolicy 266

Endovascular Occlusion of Ovarian and Internal Iliac Veins (Pelvic Congestion Syndrome)

This policy governs coverage of endovascular occlusion procedures (embolization or sclerotherapy) of the ovarian and internal iliac veins to treat pelvic congestion syndrome for Blue Cross Blue Shield - Massachusetts members across commercial and Medicare products.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyEndovascular occlusion of ovarian and internal iliac veins (pelvic congestion syndrome) — Investigational

Policy CodePolicy 266

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain precertification/prior authorization for inpatient procedures; outpatient endovascular occlusion is not a covered service for specified products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

266policy id

63.7%–100%reported success

37241investigational code

Prior auth (inpatient)precertification

Coverage Determinations

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.

Investigational — Policy statement

Policy statement

Policy stance: Endovascular occlusion of the ovarian vein and internal iliac veins is considered INVESTIGATIONAL as a treatment of pelvic congestion syndrome.

Applies to Commercial and Medicare products listed in policy header.

For outpatient services described in this policy, endovascular occlusion procedures of the ovarian and internal iliac veins are not a covered service for the following products: Commercial PPO and Indemnity, Medicare HMO BlueSM, and Medicare PPO BlueSM. Performing these procedures in the outpatient setting for members of these products may result in claim denial.

Endovascular occlusion of the ovarian vein and internal iliac veins is considered investigational as a treatment of pelvic congestion syndrome and therefore is not supported as medically necessary for Commercial and Medicare products listed in the policy header.

Provider Actions and Billing Notes

Prior Authorization

Prior Authorization Required (Inpatient)

For services described in this policy, precertification/prior authorization IS REQUIRED for all products if the procedure is performed inpatient. Lack of required prior authorization may result in claim denial or reduced payment.

Applies to all product lines when performed as an inpatient service
Contact Blue Cross Blue Shield - Massachusetts provider services or use the payer portal for authorization prior to admission

Denial Risk

Outpatient Noncoverage Risk

Outpatient procedures described in this policy are not covered for certain product lines. Performing outpatient services that are designated as non‑covered may result in claim denial and potential member financial liability.

Commercial PPO and Indemnity — Outpatient: This is not a covered service
Medicare HMO Blue — Outpatient: This is not a covered service
Medicare PPO Blue — Outpatient: This is not a covered service

Documentation Required

Coding and Documentation Guidance

Providers must report all services using the most up‑to‑date industry-standard procedure, revenue, and diagnosis codes (CPT, HCPCS, ICD-10), including appropriate modifiers, and submit supporting clinical documentation to determine coverage. Inclusion of codes in policy materials is informational only and does not guarantee coverage or reimbursement.

Use current CPT/HCPCS/ICD-10 codes and applicable modifiers
Attach clinical notes, imaging, operative reports, and prior authorization approval (when applicable) to support medical necessity
Code lists in the policy are not all-inclusive; verify member contract benefits at time of service

Background

Pelvic congestion syndrome, also referred to as a pelvic venous disorder, presents as chronic pelvic pain that is often worsened by standing and may be associated with dyspareunia or postcoital ache. Diagnostic criteria are not well defined and the condition is frequently a diagnosis of exclusion. Endovascular occlusion (for example, embolization or sclerotherapy) of the ovarian and internal iliac veins has been proposed as a treatment option, but in this policy it is considered investigational.

Definitions

Pelvic venous disorder / pelvic congestion syndrome — definition and typical symptoms

DefinitionChronic pelvic pain syndrome associated with pelvic venous varices and congestion; diagnostic criteria are not clearly defined and it is often a diagnosis of exclusion.

Typical timing and populationUsually occurs before menopause and symptoms are often greater before or during menses.

Cardinal symptomsChronic pelvic pain often aggravated by standing; may include dyspareunia, postcoital ache, and tenderness over the ovarian point.

Diagnostic approachEvaluation frequently by exclusion of other causes of chronic pelvic pain using physical exam, laboratory tests, and imaging; SVP classification proposed to standardize terminology and phenotypes.

Endovascular occlusion — procedural definition including embolization and sclerotherapy techniques and agents

Procedural definitionEndovascular occlusion refers to minimally invasive embolization or sclerotherapy procedures targeting ovarian and/or internal iliac veins to eliminate pelvic venous reflux and congestion.

TechniquesEmbolization and sclerotherapy performed via endovascular access under imaging guidance to occlude targeted pelvic veins.

Embolic agents and materialsIncludes coils, vascular plugs, glue, liquid embolic agents, and gelatin sponge or powder (Gelfoam).

Intended roleProposed as an alternative to surgical vein ligation for patients who fail conservative medical therapy.