ModifiedColorado Rocky Mountain Health PlansPolicy CS139.R

Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome

This policy governs coverage and medical necessity of embolization procedures of the ovarian and internal iliac veins to treat pelvic congestion syndrome for Colorado Rocky Mountain Health Plans members, with state exceptions listed.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyEmbolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome

Policy CodePolicy CS139.R

Change TypeClinical evidence and definitions updated

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionDo not pursue embolization of the ovarian or internal iliac veins for pelvic congestion syndrome because it is considered not medically necessary due to insufficient evidence of efficacy.

SourceLink

POLICY UPDATE CHANGES

Updated Clinical Evidence and References sections to reflect the most current information.

Removed content/language pertaining to the state of Louisiana.

Updated definitions for Internal Iliac Vein (Hypogastric Vein) and Ovarian Vein.

Insufficientevidence quality described for embolization efficacy

94%technical success rate (systematic review)

3.8%-22%complication rate range

2,038

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

individuals in 2024 review

2026-04-01policy revision date

Coverage Determinations

Not medically necessary

Coverage determination

Main policy stance: Embolization of the ovarian vein or internal iliac vein is unproven and not medically necessary for treating Pelvic Congestion Syndrome due to insufficient evidence of efficacy.

This Medical Policy does not apply to the states listed below. Refer to the state-specific policy or guideline where noted: Idaho, Indiana, Kansas, Kentucky, Nebraska, New Jersey, New Mexico, North Carolina, Ohio, Pennsylvania, and Tennessee.

Template update: content and language pertaining to the state of Louisiana were removed from this policy in the 04/01/2026 update.

Coverage determination: Embolization of the ovarian vein or internal iliac vein for Pelvic Congestion Syndrome is considered unproven and not medically necessary due to insufficient evidence of efficacy.

Coding and Product References

Applicable CPT CodesCPT

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)

FDA product code referencedmixed

KRD	Device, vascular, for promoting embolization (FDA product code)

Duration of pelvic pain — diagnostic threshold

Minimum symptom durationNoncyclic pelvic pain lasting at least 6 months

Population typically affectedWomen of reproductive age

Relation to varicositiesOften associated with varicosities of the ovarian and/or internal iliac veins

FDA information

FDA product code referencedKRD (device, vascular, for promoting embolization)

FDA database accessCenter for Devices and Radiological Health 510(k) database / Premarket Search Strategy

FDA access date

Provider Responsibilities and Authorization

Prior Authorization

Prior Authorization Required When Applicable

Prior authorization requirements vary by plan. Verify and obtain prior authorization per the member's benefit plan before scheduling embolization procedures when plan policy requires it.

Affected code: CPT 37241 (venous embolization/occlusion)

Denial Risk

Coverage Determined by Plan Terms

Embolization for Pelvic Congestion Syndrome is considered unproven and not medically necessary by this policy. Coverage determinations are governed by federal, state, and contractual benefit plan terms; if those governing requirements differ from this Medical Policy, the federal/state/contractual requirements control.

Policy coverage rationale: Embolization of the Ovarian Vein or Internal Iliac Vein is unproven and not medically necessary for PCS

Definitions

Embolization — procedure definition and typical materials

Procedure definitionEmbolization is a procedure that uses particles (e.g., gelatin sponges or beads) to block a blood vessel; used to stop bleeding or block blood flow to abnormal tissue.

Typical approachPerformed under fluoroscopic guidance with catheter-directed delivery of embolic agents following venography to visualize target veins.

Common embolic materialsMetal coils, sclerosing agents, gelatin sponges (temporary or permanent)

Pelvic Congestion Syndrome — definition

DefinitionPelvic Congestion Syndrome (PCS) is a syndrome involving chronic noncyclic pelvic pain typically associated with pelvic varices or varicosities.

Typical cause

Clinical Background

Background: Pelvic congestion syndrome (PCS) is characterized by chronic, noncyclic pelvic pain typically lasting at least 6 months and is often associated with ovarian and pelvic varices. Embolization procedures aim to occlude affected veins (for example, ovarian or internal iliac veins) using coils, sclerosing agents, or particles to reduce venous pressure and symptoms, but current evidence is insufficient to establish efficacy.

Policy Revision History

2026-04-01Template updateLatest

Template update removed Louisiana-specific language from the policy; previous version archived (CS139.Q).

2026-03-01Definitions revised

Definitions for Internal Iliac Vein (Hypogastric Vein) and Ovarian Vein were updated and supporting Clinical Evidence and References were refreshed.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyEmbolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome

Policy CodePolicy CS139.R

Change TypeClinical evidence and definitions updated

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionDo not pursue embolization of the ovarian or internal iliac veins for pelvic congestion syndrome because it is considered not medically necessary due to insufficient evidence of efficacy.

SourceLink

On This Page

Accessed October 14, 2025

CPT 37241 — definition / description

CPT code37241

Short descriptionVascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage

Coding clarificationSpecific to venous embolization/occlusion; excludes lower extremity venous incompetency (see CPT Assistant guidance)

Documentation Required

Preprocedural Assessment and Diagnostic Confirmation

Perform a comprehensive preprocedural assessment to exclude nonvascular causes of chronic pelvic pain and ensure radiologic confirmation of pelvic venous insufficiency. Recommended evaluation includes duplex ultrasound and, when indicated, computed tomography or MR phlebography; diagnostic venography may be used to visualize affected veins prior to embolization.

Require documented confirmation of venous pathology (duplex US, CT phlebography, or MR phlebography)
Document exclusion of nonvascular etiologies for pelvic pain

Documentation Required

Conservative Therapy and Documentation

Document prior conservative therapies attempted and clinical rationale for proceeding to any invasive intervention. Conservative management should be tried first and may include pharmacologic therapy (e.g., analgesics, hormonal therapy), physical therapy, and surgical options when appropriate. Maintain complete records of symptom duration (≥6 months typical for PCS), prior treatments, radiologic findings, informed consent discussion, and risks including potential effects on ovarian reserve.

Record duration of symptoms and failure of conservative care
Document informed consent including fertility risks

Documentation Required

Documentation, Governance, and Use of Decision Tools

Follow applicable documentation and governance requirements when applying this policy. Reference and comply with federal, state, and contractual requirements, and use available decision-support tools (e.g., InterQual) as applicable. This policy is informational and does not replace independent clinical judgment.

Policy is informational; in case of conflict, federal/state/contractual requirements govern
Third-party tools (e.g., InterQual) may be used to assist in coverage decisions

Varicosities of the ovarian veins and/or internal iliac veins leading to venous reflux and increased venous pressure.

Clinical contextSymptoms persist at least 6 months and primarily affect women of reproductive age; considered when conservative treatments fail.

Internal Iliac Vein (Hypogastric Vein) — definition

TermInternal Iliac Vein (Hypogastric Vein)

Updated definition summaryOne of the principal venous tributaries in the pelvis that drains deoxygenated blood from pelvic organs and receives tributaries such as middle rectal, pudendal, obturator, and vesical veins.

RoleServes as a main pathway for venous drainage from smaller pelvic veins back toward the central circulation.

Ovarian Vein — definition

TermOvarian Vein

Updated definition summaryOne of a pair of veins emerging from the broad ligament near the ovaries and uterine tubes that carries deoxygenated blood from the ovaries.

Clinical relevanceDilation or reflux of ovarian veins is implicated in pelvic congestion syndrome and may be targeted during embolization procedures.