CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

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

Defines coverage and prior authorization requirements for ovarian and internal iliac vein embolization (including coil embolization and sclerotherapy) as treatment for pelvic congestion syndrome for Medicare Advantage and Commercial members of Blue Cross Blue Shield - Rhode Island.

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 change

Effective Date11 | 01

Next Review DateN/A

Key ActionObtain prior authorization for Medicare Advantage members and ensure patient has failed a 6-month trial of appropriate pharmacotherapy before scheduling embolization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=6min pelvic pain duration (months)

6-monthfailed pharmacotherapy trial

Venography/CT/MRIrequired imaging

37241CPT code

Coverage and Medical Necessity Criteria

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Medically necessary criteria

Ovarian/internal iliac vein embolization is considered medically necessary when ALL of the following are met:

Medical necessity criteria: 1) Patient has significant pelvic pain for greater than 6 months that interferes with activities of daily living;>= 6 months

Applies to Medicare Advantage Plans and Commercial Products.

Medical necessity criteria: 2) Definitive diagnostic venography, CT, or MRI demonstrating pelvic vein incompetence/varices;

Medical necessity criteria: 3) Patient has failed a 6-month trial of appropriate pharmacotherapy including analgesics and hormonal therapy;6-month trial

Medical necessity criteria: 4) Procedure is ovarian vein embolization or trans‑venous occlusion using metallic coils or foam/gel sclerotherapy (CPT 37241 describes vascular embolization/occlusion, venous).

Ovarian and internal iliac vein embolization (including trans‑venous occlusion using metallic coils or foam/gel sclerotherapy) is not covered / not medically necessary when the specified medical necessity criteria are not met. This applies to procedures intended for treatment of pelvic congestion syndrome with varices and includes cases where required documentation, diagnostic imaging, or prior failed medical therapy are absent.

For Medicare Advantage Plans, the procedure is not covered when the medical criteria above are not met.

For Commercial Products, ovarian/internal iliac vein embolization or trans‑venous occlusion (metallic coils or foam/gel sclerotherapy) for pelvic congestion syndrome with varices is considered not medically necessary when the medical criteria above are not met.

Billing and Coding

Covered CPT CodesCPTCovered

37241

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

Associated ICD-10 Diagnosis CodesICD-10

N94.89

Other specified conditions associated with female genital organs and menstrual cycle (listed as ICD-10 diagnosis)

Provider Requirements and Authorization

Prior Authorization

Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products.

Documentation Required

Failed Medical Therapy Prerequisite

Patients must have failed a 6-month trial of appropriate pharmacotherapy including analgesics and hormonal therapy before embolization is considered.

Documentation Required

Recommended Medical Records

Recommended documentation to include: current medication list, history and physical, radiology report (CT or MRI), office notes, duplex scan, and diagnostic venography report.

Current medication list
History and physical report
Radiology report (CT or MRI)
Office notes
Duplex scan
Diagnostic venography report

Denial Risk

Denial Risk When Criteria Unmet

Procedure is not covered / not medically necessary when the specified medical criteria are not met for both Medicare Advantage Plans and Commercial Products. For Medicare Advantage Plans this is a coverage exclusion when criteria are unmet; for Commercial Products the procedure is considered not medically necessary when criteria are unmet.

Background

Pelvic congestion syndrome (PCS) is a condition of chronic pelvic pain often associated with varices of the ovarian veins, typically worse with prolonged standing and frequently occurring in reproductive‑age, multiparous women. Symptoms may include chronic pelvic heaviness, dyspareunia, and postcoital pain.

Pathophysiology is thought to involve ovarian vein dilatation with venous stasis and reflux; diagnosis commonly relies on imaging such as diagnostic venography, CT, or MRI and is frequently a diagnosis of exclusion.

When medical therapy fails, embolization of ovarian and/or internal iliac veins (using coils or sclerotherapy) has been proposed as a treatment option, though supporting evidence is largely from case series rather than randomized controlled trials.

Key Definitions

Pelvic congestion syndrome (PCS): definition and associated clinical features

DefinitionChronic pelvic pain syndrome associated with varices of the ovarian veins and pelvic venous congestion; pain is often aggravated by standing and may be associated with dyspareunia and postcoital pain

Typical patient populationOccurs during reproductive years and is frequently seen in multiparous, premenopausal women

Key clinical featuresChronic pelvic pain (variable location/intensity) that interferes with activities of daily living, standing-aggravated pain, and dyspareunia/postcoital pain

Associated imaging findingsOvarian vein dilatation, stasis, and/or reflux demonstrated by diagnostic venography, CT, or MRI (varices may be identified by imaging)

Diagnostic considerationsOften a diagnosis of exclusion because multiple etiologies cause chronic pelvic pain; definitive imaging is used to identify pelvic vein incompetence/varices