CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

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

This policy governs coverage of endovascular embolization (ovarian and/or internal iliac veins) as a treatment for 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 Date

Key ActionDo not submit claims for ovarian or internal iliac vein embolization for pelvic congestion syndrome; the procedure is considered not covered/not medically necessary.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredCoverage stance for embolization treatment

~80%Reported symptomatic improvement

37241Procedure code

N94.89Diagnosis code

Coverage Determination

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Not covered / Not medically necessary

Covered when ALL of the following are met:

Primary coverage statement: Embolization of the ovarian and internal iliac veins is considered not covered / not medically necessary as a treatment of pelvic congestion syndrome because the evidence is insufficient to determine effects on health outcomes.

Statement applies to Commercial Products and Medicare Advantage where specified.

Embolization of the ovarian and internal iliac veins for the treatment of pelvic congestion syndrome is not covered / not medically necessary. The policy statement indicates the evidence is insufficient to determine the effects of the technology on health outcomes, and therefore this procedure is excluded from coverage for the indicated condition.

The available evidence consists primarily of case series and a systematic review of those series; there are no randomized controlled trials comparing embolization to placebo or alternative interventions. Although case-series data report symptomatic improvement in about 80% of patients, the lack of controlled data, heterogeneous and variable definitions of pelvic congestion syndrome, and unclear patient selection limit confidence in these findings. For these reasons the evidence is considered insufficient to demonstrate that ovarian or internal iliac vein embolization improves health outcomes, and the procedure is therefore considered not medically necessary.

Billing and Coding

Not covered / Not medically necessary CPT codeCPTNot 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 code listed with not-covered CPTICD-10

N94.89

Other specified conditions associated with female genital organs and menstrual cycle (used here as pelvic pain diagnosis)

Provider Requirements and Billing Guidance

Prior Authorization

Not applicable

Note

Benefit Verification

Benefits may vary by contract. Refer to the member's Benefit Book, Evidence of Coverage, or Subscriber Agreement to determine applicable benefits and coverage for this service.

Billing Rule

Billing note

When billed with ICD-10 diagnosis code N94.89, CPT 37241 is listed as not covered for Medicare Advantage plans and considered not medically necessary for Commercial Products.

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

Denial Risk

Denial risk for embolization

Claims for embolization of the ovarian vein and internal iliac veins as a treatment for pelvic congestion syndrome are considered not covered / not medically necessary.

Clinical Background

Pelvic congestion syndrome is a clinical condition characterized by chronic pelvic pain that is often worsened by standing. Diagnostic criteria are not well-defined, and case definitions vary across reports, which complicates identification of a consistent patient population. Embolization (endovascular occlusion) of the ovarian and internal iliac veins has been proposed for patients who fail medical therapy, but available data are limited to uncontrolled case series and systematic reviews of those series, leaving diagnostic uncertainty and uncertain treatment benefit.

Key Definitions

Pelvic congestion syndrome — definition and clinical features

DefinitionA condition characterized by chronic pelvic pain often aggravated by standing; diagnostic criteria are not well-defined.

Proposed treatmentEndovascular occlusion (eg, embolization or sclerotherapy) of the ovarian and internal iliac veins has been proposed for patients who fail medical pain therapy.

Evidence summaryAvailable evidence consists primarily of case series and a systematic review; approximately 80% symptomatic improvement reported in case series, but lack of randomized controlled trials and variable definitions limit conclusions.

Clinical challengeVariable definitions of pelvic congestion syndrome make it difficult to clearly define a patient population with symptoms attributable to pelvic venous reflux.

Implication for coverageBecause evidence is insufficient to determine effects on health outcomes, embolization is considered not medically necessary for treatment of pelvic congestion syndrome.