CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome

This policy addresses coverage and medical necessity of endovascular occlusion (embolization or sclerotherapy) of ovarian and internal iliac veins for treatment of pelvic congestion syndrome for Blue Cross Blue Shield - Rhode Island members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyOvarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 12, 2014

Next Review DateN/A

Key ActionVerify member benefits in the Benefit Book, Evidence of Coverage, or Subscriber Agreement before submitting claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not covered / Not medically necessaryCoverage stance

37241Not covered CPT

N94.89Associated ICD-10

63.7-100%Reported success

Coverage Determination

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General coverage determination

Covered when ALL of the following are met:

Coverage determination: Embolization of the ovarian vein and internal iliac veins is considered not covered for Medicare Advantage and not medically necessary for Commercial products because the evidence is insufficient to determine the effects on health outcomes.

Systematic reviews report variable success but randomized trials with well-defined eligibility and relevant comparators are needed.

Embolization of the ovarian vein and internal iliac veins is explicitly not covered for Medicare Advantage members and is considered not medically necessary for Commercial products because the evidence is insufficient to determine the effects of the technology on health outcomes. Benefits may vary by group and contract; providers should consult the member's Benefit Book, Evidence of Coverage, or Subscriber Agreement for applicable coverage and non-covered benefits.

For Commercial products, embolization of the ovarian and internal iliac veins for treatment of pelvic congestion syndrome is considered not medically necessary. Specifically, CPT 37241 when filed with ICD-10 code N94.89 is listed as not medically necessary for this indication.

Coding and Billing

Not covered / Not medically necessary CPT codesCPTNot Covered

37241

Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)

Associated ICD-10 Diagnosis CodeICD-10

N94.89

Other specified conditions associated with female genital organs and menstrual cycle (used here as ICD-10 diagnosis code associated with pelvic congestion syndrome)

Provider Requirements and Billing Impact

Prior Authorization

Prior authorization: Not applicable for this policy. Providers do not need to obtain prior authorization before performing evaluation or procedures related to pelvic congestion syndrome under this policy.

Step Therapy

Medical Therapy Failure

Medical therapy failure context: Embolization (endovascular occlusion of ovarian and/or internal iliac veins) is described as a treatment option for patients who have failed medical therapy. The policy does not specify formal step-therapy requirements or mandated trials of particular medications prior to considering embolization.

Documentation Required

Verify Member Benefits

Verify member benefits: Benefits and coverage vary by contract. Providers should check the member's Benefit Book, Evidence of Coverage (EOC), or Subscriber Agreement to confirm applicable coverage, limitations, and member cost-sharing before proceeding.

Denial Risk

Coverage Denial Risk

Coverage and billing risk for embolization (CPT 37241): Claims for CPT code 37241 filed with ICD-10 code N94.89 are considered not covered for Medicare Advantage plans and not medically necessary for Commercial products under this policy; such claims are at risk for denial.

Affected CPT: 37241
Affected ICD-10: N94.89

Clinical Background

Pelvic congestion syndrome is a chronic condition characterized by pelvic pain that is often aggravated by standing. The diagnosis lacks well-defined, universally accepted criteria. Endovascular occlusion procedures — including coil embolization, vascular plugs, or sclerotherapy of the ovarian and/or internal iliac veins — have been proposed as treatments for patients who fail medical therapy; however, the available evidence is variable and insufficient to establish clear net health benefit.

Key Definitions

Pelvic congestion syndrome — definition and key features

DefinitionA clinical syndrome characterized by chronic pelvic pain that is often aggravated or worse with standing; diagnostic criteria are not well-defined.

Typical symptom patternChronic pelvic pain with worsening of pain when standing (orthostatic exacerbation).

Diagnostic clarityDiagnostic criteria are not clearly defined in the literature and within the policy.

Clinical context for interventionEndovascular occlusion (eg, embolization or sclerotherapy) has been proposed for patients who fail medical therapy.

Reported outcomes in studiesPublished series report clinical success (pain reduction) ranging from approximately 63.7% to 100%, but evidence is considered insufficient to determine net health benefit.

Endovascular occlusion / embolization — procedure definitions

DefinitionMinimally invasive endovascular procedures intended to occlude ovarian and/or internal iliac veins to treat pelvic venous reflux associated with pelvic congestion syndrome.

Common techniquesCoil embolization, vascular plugs, and sclerotherapy (endovascular occlusion methods).

PurposeTo reduce venous reflux and pelvic venous hypertension believed to contribute to chronic pelvic pain in pelvic congestion syndrome.

Anesthesia and procedural notesProcedures are typically performed endovascularly and may be done under local anesthesia; alternative surgical options (eg, resection) may require general anesthesia.

Evidence summaryRandomized and observational studies report variable clinical success and adverse event rates; randomized trials with well-defined comparators are needed and overall evidence is insufficient to confirm net health benefit.