Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
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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.
No material clinical or coverage changes in this revision.
Coverage Determination
General coverage determination
Covered when ALL of the following are met:
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
| 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) |
| 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.
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.
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.
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
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