Ovarian and internal iliac vein endovascular occlusion for pelvic congestion syndrome
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This policy governs coverage of endovascular occlusion (embolization/sclerotherapy) of ovarian and internal iliac veins to treat pelvic congestion syndrome for Capital Blue Cross products and programs; applicability may vary by product and member benefit plan.
Policy retired; no material updates to clinical coverage in this revision.
Coverage Determination
Coverage determination — investigational
Policy coverage determination
Based on evidence including randomized studies, comparative studies, case series, and systematic reviews showing variable definitions, limited RCT data, and need for better trials.
Randomized controlled trials with well-defined criteria and relevant comparators are needed.
Endovascular occlusion of the ovarian and internal iliac veins for the treatment of pelvic congestion syndrome is considered investigational due to insufficient evidence that the procedure improves net health outcomes.
Evaluation for pelvic venous varices in suspected pelvic congestion syndrome
Imaging helps identify varices but pelvic congestion syndrome remains a diagnosis of exclusion.
The following procedure code is not covered when used for embolization and/or sclerotherapy of the ovarian and internal iliac veins for the treatment of pelvic congestion syndrome: CPT 37241.
This policy's history notes a retirement event on 6/5/2024; providers should verify current applicability and benefit coverage with Capital Blue Cross and the member's plan, as retired policy status may affect coverage determinations.
Procedure and Billing Codes
| 37241 | Transcatheter occlusion or embolization, percutaneous, vessel(s) of pelvic veins (as listed) - not covered when used for embolization and/or sclerotherapy of the ovarian and internal iliac veins for the treatment of pelvic congestion syndrome |
Provider Requirements and Actions
Preauthorization may be required — verify plan rules
The existence of this medical policy does not guarantee coverage under a member's health benefit plan; coverage is determined by the terms of the applicable plan and some services may require preauthorization per the member's product design.
- “A member's health benefit plan governs which services are covered… and which require preauthorization.”
Prior authorization — no explicit requirement in policy text
The policy text does not specify an internal Capital Blue Cross prior authorization program requirement for these procedures; providers should rely on the member's benefit plan for any prior authorization rules.
- Policy notes procedure is investigational and not covered for this indication; separate preauthorization requirements are determined by the member's health benefit plan.
Conservative therapy recommended before procedural interventions
Initial (conservative) treatment is recommended before procedural interventions for pelvic congestion syndrome: psychotherapy, medical therapy (e.g., NSAIDs), and hormonal therapy; surgical ligation of the ovarian vein may be considered for patients who fail initial therapy.
- “Initial treatment of pelvic congestion syndrome includes psychotherapy and medical therapy (e.g., nonsteroidal anti-inflammatory drugs) and hormonal therapy.”
- “For patients who fail initial therapy, surgical ligation of the ovarian vein may be considered.”
No step therapy requirements described
The document does not describe any formal step therapy sequence or mandated step requirements for endovascular occlusion procedures.
- Source treatment section describes initial conservative therapies but the policy does not mandate step therapy requirements.
Benefit verification required — check member plan
Providers must verify benefits with the member's health plan; benefit determinations should be based on the applicable health benefit plan language and providers or members may contact Capital Blue Cross for benefit information.
- “Benefit determinations should be based in all cases on the applicable health benefit plan language.”
- “Members and providers should consult the member's health benefit plan for information or contact Capital Blue Cross for benefit information.”
Investigational status — may result in denial for this indication
Endovascular occlusion of the ovarian and internal iliac veins for pelvic congestion syndrome is labeled investigational in this policy; when a service is investigational it may be denied as not covered for this indication.
- “Endovascular occlusion of the ovarian vein and internal iliac veins for the treatment of pelvic congestion syndrome is considered investigational; therefore, the following codes are not covered when used for embolization and/or sclerotherapy of the ovarian and internal iliac veins for the treatment of pelvic congestion syndrome:”
- The coverage determination states the procedure is investigational due to insufficient evidence of benefit.
Policy history and references — consult for justification
Review the policy history and references when preparing clinical justification: the policy documents multiple consensus reviews with the policy statement unchanged and includes revisions to terminology, rationale, and references.
- Policy history entries note repeated consensus reviews with the policy statement unchanged and revisions such as changing 'embolization' to 'endovascular occlusion'.
- Retirement entry dated 6/5/2024 is recorded in policy history and should be considered when referencing the policy.
Policy statement unchanged through reviews; retirement noted
The policy statement was unchanged through multiple consensus reviews and the document records a retirement date (6/5/2024); providers should note these history items as they may affect coverage determinations or applicability.
- “Policy Statement unchanged. Policy title and language revised from 'embolization' to 'endovascular occlusion' for clarification.”
- “6/5/2024 Retirement.”
Definitions and Terminology
Background and Clinical Context
Pelvic congestion syndrome is a chronic pelvic pain condition associated with ovarian vein varices and pelvic venous congestion, most commonly affecting women of reproductive age. It is often a diagnosis of exclusion; not all women with pelvic venous reflux have chronic pelvic pain. Imaging such as MRI, CT, or contrast venography may be used to identify pelvic varices, and initial management typically includes conservative measures (for example, psychotherapy, NSAIDs, and hormonal therapy) before considering procedural interventions.
Not Covered Procedures
Endovascular occlusion (embolization/sclerotherapy) of the ovarian and internal iliac veins for pelvic congestion syndrome is considered investigational and therefore is not covered under this policy. Procedure coding for this indication is restricted (see coding section), and benefit determinations should be confirmed with the member's benefit plan.
Policy History
Policy retired as noted in policy history.
Policy statement unchanged; rationale and references updated.
Policy statement unchanged; definitions and references updated.
Policy statement unchanged; rationale and references updated.
Policy statement unchanged; title and language revised from 'embolization' to 'endovascular occlusion'; FEP variation removed; description/background and rationale updated; references added.
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