RetiredCapital BluecrossPolicy MP 1.116

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

This policy governs coverage and coding for endovascular occlusion (embolization/sclerotherapy) of ovarian and internal iliac veins when used to treat pelvic congestion syndrome for Capital Blue Cross products; it affects providers performing these procedures and benefits administrators adjudicating claims.

Policy Summary

PayerCapital Bluecross

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

Policy CodePolicy MP 1.116

Change TypeRetirementtitle clarificationFEP variation removed

Effective DateRETIRED 11/1/2024

Next Review Date

Key ActionVerify member benefits and preauthorization requirements with Capital Blue Cross because the policy is retired and coverage may no longer be governed by this document.

SourceLink

POLICY UPDATE CHANGES

Policy title language was revised from 'embolization' to 'endovascular occlusion' for clarification.

FEP variation was removed as FEP policy no longer in effect.

Policy was retired effective 6/5/2024.

InvestigationalPolicy stance on procedure

37241Not covered code

63.7%–100%Clinical success (reported)

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MP 1.116Policy number

Coverage Determinations

Investigational / Not medically necessary

Covered when ALL of the following are met:

Investigational determination: Endovascular occlusion of the ovarian vein and internal iliac veins for the treatment of pelvic congestion syndrome is considered investigational due to insufficient evidence to support a general conclusion concerning health outcomes or benefits.

See Summary of Evidence for details on available studies, reported clinical success rates, and limitations.

Policy retirement / evidence summary

Policy status and evidence citations:

Policy state: The policy MP 1.116 addressing ovarian and internal iliac vein endovascular occlusion for pelvic congestion syndrome has been retired as of 6/5/2024.

No active coverage criteria present in this excerpt; consult the administrator or current plan documents for replacement guidance.

Summary of evidence: Published evidence includes randomized trials, comparative studies, case series, and systematic reviews reporting variable clinical success (reported ranges approximately 63.7%–100%) and procedure-related adverse events; randomized controlled trials with well-defined eligibility and relevant comparators are needed, and the evidence is insufficient to demonstrate net health benefit.

See referenced literature for study-level details: systematic reviews and multiple observational studies (see reference list).

Endovascular occlusion of the ovarian veins and internal iliac veins for the treatment of pelvic congestion syndrome is designated as investigational by this policy. The procedure is considered investigational because there is insufficient evidence to support a general conclusion regarding net health outcomes or benefits for this indication; consequently it is excluded from coverage under this policy.

The policy history documents an operational change in terminology: the policy title and language were revised from 'embolization' to 'endovascular occlusion' for clarification. The history also notes removal of the FEP variation because the FEP policy is no longer in effect; see the Policy History for details.

Supporting excerpt: 'Endovascular occlusion of the ovarian vein and internal iliac veins for the treatment of pelvic congestion syndrome is considered investigational' — this statement is the basis for the investigational determination and exclusion from coverage under this policy.

Note: the provided excerpts and policy history record do not consistently present the phrase 'not medically necessary' verbatim. The policy uses the term investigational to indicate lack of coverage for this procedure, and the retirement entry indicates the policy was retired effective 6/5/2024.

Procedure and Billing Codes

Not covered procedure codes for this indicationCPTNot Covered

37241

Transcatheter occlusion or embolization, venous (eg, for pelvic venous embolization) (listed in policy as not covered when used for embolization and/or sclerotherapy of the ovarian and internal iliac veins for pelvic congestion syndrome)

No explicit codes in this excerptmixed

No codes listed

Provider Requirements and Next Steps

Prior Authorization

Benefit verification and preauthorization

The existence of this medical policy does not guarantee that endovascular occlusion of the ovarian or internal iliac veins is a covered benefit under a member's health plan. Benefit determinations must be made based on the member's specific health benefit plan language; medical policies do not replace plan terms. Preauthorization and benefit verification may be required and vary by product — contact Capital Blue Cross or consult the member's plan to confirm coverage and any prior authorization requirements.

Benefit determinations based on member health benefit plan language
Preauthorization and benefit verification requirements vary by product

Note

Policy retirement effect

This policy was retired effective 6/5/2024. When a policy is retired, existing authorization rules and internal guidance tied to this policy may no longer apply — providers should verify current coverage policies, prior authorization processes, and clinical criteria with Capital Blue Cross to determine how claims for these services will be handled going forward.

Clinical Background

Pelvic congestion syndrome is a chronic pelvic pain disorder associated with dilated pelvic veins (varices), commonly involving the ovarian veins and sometimes the internal iliac veins. Clinical features reported in the policy background include chronic pelvic pain that may worsen with standing and dyspareunia; diagnosis is typically one of exclusion supported by imaging such as MRI, CT, or venography. Endovascular occlusion (formerly termed embolization) has been proposed as a minimally invasive alternative to surgical ligation, using devices or agents such as coils, plugs, sclerosants, glue, or Gelfoam, but available randomized and observational studies are variable and overall considered insufficient to establish a net health benefit.

Key Terms and Definitions

Dyspareunia — definition entry

TermDyspareunia

DefinitionPain in the labia, vagina, or pelvis during or after sexual intercourse.

ContextListed under Definitions for pelvic congestion syndrome policy MP 1.116.

Internal iliac vein — definition entry

TermInternal iliac vein (hypogastric vein)

DefinitionVeins that originate deep in the pelvic region and extend to the lower portion of the abdomen, where they join the right and left iliac veins to form the common iliac veins.

Context

Policy Summary

PayerCapital Bluecross

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

Policy CodePolicy MP 1.116

Change TypeRetirementtitle clarificationFEP variation removed

Effective DateRETIRED 11/1/2024

Next Review Date

Key ActionVerify member benefits and preauthorization requirements with Capital Blue Cross because the policy is retired and coverage may no longer be governed by this document.

SourceLink

On This Page

Policy retirement date: 6/5/2024

Confirm current authorization and coverage rules with payer

Documentation Required

Prior conservative therapies

Document the patient's prior conservative therapies and clinical course before considering procedural therapy. Initial conservative treatments for pelvic congestion syndrome typically include psychotherapy, NSAIDs, and hormonal therapy. If these conservative measures fail, surgical ovarian vein ligation is an established option and embolization/endovascular occlusion has been proposed but is considered investigational for this indication.

Conservative therapies: psychotherapy; nonsteroidal anti-inflammatory drugs (NSAIDs); hormonal therapy
Surgical option after failure of conservative therapy: ovarian vein ligation
Note: embolization/endovascular occlusion is considered investigational for PCS

Documentation Required

Documentation note

This policy document (MP 1.116) lists endovascular occlusion for pelvic congestion syndrome as investigational and identifies procedure code(s) that are not covered when used for this indication. The excerpt does not specify additional active documentation or submission steps; however, providers should include clinical rationale, prior conservative therapy documentation, and any required preauthorization/benefit-verification information when submitting requests or claims.

Policy title/number: OVARIAN AND INTERNAL ILIAC VEIN ENDOVASCULAR OCCLUSION AS A TREATMENT OF PELVIC CONGESTION SYNDROME — MP 1.116
Not-covered procedure code when used for PCS: 37241
Include documentation of prior conservative therapies and preauthorization/benefit verification as applicable

Anatomical structure referenced in pelvic congestion syndrome definitions and treatment considerations.

Ovarian vein — definition entry

TermOvarian vein

DefinitionOne of a pair of veins that emerge from the broad ligament near the ovaries and the uterine tubes.

ContextTarget vessel for endovascular occlusion/embolization in pelvic congestion syndrome discussions.

Therapeutic embolization — definition entry

TermTherapeutic embolization

DefinitionThe obstruction of a blood vessel by intentionally injected material.

ContextDescribes the mechanism by which coils, plugs, sclerosants, or other agents occlude pelvic veins.

Varices — definition entry

TermVarices

DefinitionTortuous, dilated veins.

ContextVarices of the ovarian veins are associated with pelvic congestion syndrome.

Endovascular occlusion — terminology revision note

TermEndovascular occlusion (formerly termed embolization)

DefinitionPolicy language revised to use 'endovascular occlusion' instead of 'embolization' for clarification.

ContextOperational terminology change noted in policy history for MP 1.116; reflects preferred wording in policy text.