CurrentUnitedHealthcarePolicy CS139KS.02

Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome (for Kansas Only)

Defines UnitedHealthcare Community Plan coverage stance for embolization of ovarian and internal iliac veins to treat pelvic congestion syndrome in Kansas members and provides supporting evidence, definitions, and coding guidance.

Policy Summary

PayerUnitedHealthcare Community Plan

PolicyEmbolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome (for Kansas Only)

Policy CodePolicy CS139KS.02

Change TypeUpdated clinical evidenceremoved ICD-10 code listrevised definitions

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionProvide venography and procedural documentation including visualization of affected veins and details of embolic agents when submitting a request or claim.

SourceLink

POLICY UPDATE CHANGES

Removed list of ICD-10 diagnosis codes: I86.2, N94.89, and R10.2.

Definitions updated for 'Embolization'.

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

94%technical success (Hanna et al. 2024)

0–42%symptom recurrence range

3.8%–22%complication rate range (Hayes)

75%early substantial relief (pooled review)

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1.6%coil migration rate

Coverage Determination

Not medically necessary / Unproven

Covered when ALL of the following are met

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

Policy applies to Kansas only

Consideration after failed conventional therapy

Contextual consideration

Consideration after conservative therapy: Embolization has been investigated for individuals who fail to adequately respond to conventional treatments (pharmacologic therapy or surgical intervention).>= 6 months of symptoms may be consistent with PCS descriptions

This consideration does not establish medical necessity under this policy; inclusion in clinical investigation or use after conservative therapy does not guarantee coverage.

UnitedHealthcare considers embolization of the ovarian vein or internal iliac vein for treatment of Pelvic Congestion Syndrome (PCS) to be unproven and not medically necessary. The policy rationale states there is insufficient evidence of efficacy to support coverage for this indication; as a result, claims for these embolization procedures may be denied.

In other words, embolization procedures targeting the ovarian vein or internal iliac (hypogastric) vein to manage PCS are explicitly characterized by the plan as not medically necessary because current evidence does not demonstrate adequate benefit for this use. Providers should anticipate that benefit determinations will not favor coverage for these services for PCS.

Coding and Timeframe Details

Coding clarification (procedure)CPT

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)

Duration of symptoms — eligibility consideration

Required symptom duration>= 6 months

Symptom typeNoncyclic pelvic pain and discomfort

Typical affected populationWomen of reproductive age

Provider Responsibilities and Billing Notes

Prior Authorization

Prior Authorization and Coding Note

Prior authorization is required for pelvic vein embolization procedures. Submit requests that include the specific CPT code 37241 (embolization/occlusion of venous structure) when applicable. Note that listing a code in this policy does not guarantee coverage; benefit determination is subject to contractual terms and medical necessity review.

Affected code: CPT 37241 — use on prior auth and claim submissions when embolization of ovarian or internal iliac veins is performed.
Include relevant diagnosis codes for pelvic congestion syndrome when known.

Note

Conservative Therapy Prerequisite

Embolization of the ovarian or internal iliac veins should be considered only after an inadequate response to conservative therapies. Providers should document trials of conventional treatments such as pharmacologic management, pelvic pain care pathways, and any surgical interventions attempted prior to embolization.

Conservative therapies may include pharmacologic therapy, pelvic pain management, and surgical options; embolization is investigated only after inadequate response.

Background and Clinical Context

Pelvic Congestion Syndrome (PCS) is a clinical syndrome of chronic pelvic pain thought to be related to pelvic venous varices or venous incompetence. It most commonly affects reproductive‑age women and is associated with noncyclic pelvic pain persisting over time. Embolization techniques aim to occlude refluxing pelvic veins (for example, ovarian or internal iliac veins) to reduce venous pressure, but per the policy the available evidence is insufficient to establish efficacy for this indication.

Definitions

Embolization — definition

DefinitionA procedure that uses particles (e.g., gelatin sponges, metal coils, beads) or sclerosants to occlude a blood vessel under fluoroscopic guidance to stop bleeding or block blood flow to abnormal tissue

Purpose in PCSTo occlude refluxing ovarian or internal iliac veins so blood flow is rerouted and venous pressure in target veins is reduced

Common embolic agentsMetal coils, sclerosing agents, gelatin sponges; agents may be temporary or permanent

Internal Iliac Vein (Hypogastric Vein) — definition

Anatomic descriptionPrimary pelvic vein (hypogastric vein) supplying the pelvic viscera and contributing to the pelvic wall, perineum, gluteal region, and thigh

Relevance to PCS

Policy Summary

PayerUnitedHealthcare Community Plan

PolicyEmbolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome (for Kansas Only)

Policy CodePolicy CS139KS.02

Change TypeUpdated clinical evidenceremoved ICD-10 code listrevised definitions

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionProvide venography and procedural documentation including visualization of affected veins and details of embolic agents when submitting a request or claim.

SourceLink

On This Page

When submitting prior authorization, include documentation of prior conservative treatment and duration/outcomes.

Documentation Required

Required Procedural Documentation

Providers must include specific procedural documentation with claims and prior authorization requests to support medical necessity. Essential elements include venographic confirmation of ovarian/internal iliac venous reflux or varicosities, description of targeted veins, embolic agents used, and technical success.

Venography/visualization: images and report confirming affected veins and reflux.
Targeted veins: specify ovarian vein, internal iliac vein, or both, and laterality.
Embolic agents: list agent types (e.g., coils, sclerosing agents, gelatin sponge) and whether temporary or permanent.
Procedure details: catheter approach, fluoroscopic guidance, complications, and immediate technical outcome.
Operative report and pre/post-procedure notes should be submitted with the request.

Denial Risk

Denial Risk for Embolization in PCS

Embolization of the ovarian or internal iliac veins for Pelvic Congestion Syndrome is considered unproven and not medically necessary based on insufficient evidence of efficacy. Such requests may be denied. Ensure that prior authorization includes strong supporting clinical documentation; absence of evidence of benefit or inadequate documentation increases risk of denial.

Denial risk applies when embolization is requested specifically for treatment of PCS.
Lack of documented failure of conservative therapy, absent venographic confirmation, or missing procedural details may lead to denial.

Internal iliac veins can develop varicosities and may be targeted for embolization because of close proximity to ovarian veins and contribution to pelvic venous congestion

Role in embolizationMay be embolized in addition to ovarian veins when venography shows involvement

Ovarian Vein — definition

Anatomic descriptionOne of a pair of veins that emerge from the broad ligament near the ovaries and uterine tubes

Relevance to PCSOvarian vein reflux and varicosities are believed to contribute to pelvic congestion syndrome and are common targets for embolization

Procedural noteVenography is used to visualize affected ovarian veins prior to embolization

Pelvic Congestion Syndrome (PCS) — definition and features

Syndrome definitionA condition involving chronic pelvic pain usually associated with varices or varicosities in the pelvic area

Clinical featuresNoncyclic pelvic pain and discomfort lasting at least 6 months

EtiologyVaricosities of the ovarian and/or internal iliac veins (pelvic venous incompetence or ovarian vein reflux) are believed to contribute

Typical patient populationTypically affects women of reproductive age