Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
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This policy governs coverage and medical necessity criteria for endovascular occlusion (embolization or sclerotherapy) of ovarian and internal iliac veins to treat pelvic congestion syndrome for BCBS Rhode Island Medicare Advantage and Commercial members.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Medical Necessity Criteria
Covered when ALL of the following are met:
Duration required before considering embolization or trans‑venous occlusion.
Imaging must confirm pelvic vein incompetence or varices prior to intervention.
Conservative medical therapy must be attempted and documented prior to embolization.
Ovarian vein embolization or trans-venous occlusion using metallic coils or foam/gel sclerotherapy of pelvic vein incompetence for the treatment of pelvic congestion syndrome with varices is not covered / not medically necessary when the medical necessity criteria outlined in this policy are not met.
For Commercial Products: ovarian vein embolization or trans-venous occlusion using metallic coils or foam/gel sclerotherapy of pelvic vein incompetence for the treatment of pelvic congestion syndrome with varices is not medically necessary when the medical criteria outlined in this policy are not met.
Provider Requirements and Documentation
Prior Authorization Required
Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products. Submit prior authorization requests per payer procedures before scheduling the procedure to avoid claim denials or delays.
- Applies to CPT 37241 when billed with diagnosis N94.89
- Required for Medicare Advantage; recommended for Commercial
Denial Risk When Criteria Not Met
Ovarian vein embolization or trans-venous occlusion is not covered / is not medically necessary when the policy's clinical criteria are not met. Claims submitted without documentation demonstrating the required criteria may be denied.
- Denial risk if patient does not have >= 6 months of significant pelvic pain interfering with ADLs
- Denial risk if no definitive diagnostic venography, CT, or MRI is documented
- Denial risk if no 6-month trial of appropriate pharmacotherapy including analgesics AND hormonal therapy is documented
Required Documentation
Recommended medical records to support medical necessity include but are not limited to the following. Include documentation with the prior authorization request and retain copies for the medical record.
- Current medication list (showing analgesics and hormonal therapy)
- History & physical report and relevant office notes documenting symptom duration and functional impact
- Radiology report(s): diagnostic venography, pelvic CT or MRI
- Duplex scan (if performed)
- Procedural reports and any prior interventional or surgical treatment notes
Required Conservative Therapy
A trial of conservative therapy is required prior to consideration of embolization. Document failure of nonprocedural management in the medical record.
- Failure of a 6-month trial of appropriate pharmacotherapy including analgesics AND hormonal therapy is required
- Conservative therapy must be clearly documented in the medication list and office notes
Coding — CPT and Diagnosis Codes
| 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 |
Background
Pelvic congestion syndrome (PCS) is a condition of chronic pelvic pain, often aggravated by standing and commonly associated with dyspareunia. It is more frequently observed in reproductive-age, multiparous women and is thought to result from ovarian vein varices with incompetence and reflux. Diagnosis is typically made by imaging such as venography, CT, or MRI and is often a diagnosis of exclusion.
Contributing anatomic factors can include pelvic venous dilation and reflux as well as the nutcracker phenomenon—extrinsic compression of the left renal vein between the aorta and superior mesenteric artery—which may produce left-sided pelvic congestion, flank pain, and hematuria.
Endovascular treatments such as embolization or sclerotherapy of ovarian and internal iliac veins have been proposed for patients who have failed conservative medical therapy, although randomized controlled trial evidence comparing these interventions to sham or alternative treatments is limited.
Key Definitions
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