Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
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This policy governs coverage determinations for embolization of the ovarian and internal iliac veins as a treatment for pelvic congestion syndrome for Blue Cross Blue Shield - Rhode Island members, addressing Medicare (BlueCHiP for Medicare) and commercial products.
No material clinical or coverage changes in this revision.
Coverage Determinations
Coverage determinations
Covered when ALL of the following are met:
Benefits for ovarian and internal iliac vein embolization may vary between groups and contracts. Refer to the member's Benefit Book, Evidence of Coverage, or Subscriber Agreement for information on applicable not medically necessary or not covered benefits and coverage.
For commercial products, embolization of the ovarian vein and internal iliac veins is considered not medically necessary as a treatment of pelvic congestion syndrome because the evidence is insufficient to determine effects on health outcomes.
Coding
| 37241 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary complete the intervention; venous, other than hemorrhage (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) |
| N94.89 | Other specified conditions associated with female genital organs and menstrual cycle (listed in policy as the diagnosis code filed with the CPT) |
Provider Actions and Requirements
Prior authorization
Not applicable.
Benefit documentation reference
Benefits may vary between groups and contracts. Refer to the appropriate Benefit Book, Evidence of Coverage, or Subscriber Agreement for applicable benefits and for determinations of not medically necessary or not covered services.
Coverage denial risk
For BlueCHiP for Medicare, embolization of the ovarian and internal iliac veins for pelvic congestion syndrome is considered not covered. For Commercial Products, embolization of the ovarian and internal iliac veins for pelvic congestion syndrome is considered not medically necessary.
Therapy context
This policy does not establish step-therapy requirements. Prior medical therapy with analgesics is noted in the clinical background but specific step therapy protocols are determined by the member's plan and benefits.
Background
Pelvic congestion syndrome is characterized by chronic pelvic pain that is often aggravated by standing; diagnostic criteria for the condition are not well-defined. Embolization of the ovarian and internal iliac veins has been proposed for patients who fail medical therapy. Case series and a systematic review report that about 80% of patients had some symptom relief at 12 months, but the evidence is limited by lack of placebo or comparative trials and by variable definitions of the condition, making it difficult to draw definitive conclusions about effectiveness.
Definitions
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