CurrentUnitedHealthcarePolicy CS139NJ.O

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

UnitedHealthcare Community Plan medical policy for New Jersey only that defines coverage stance, rationale, definitions, evidence, applicable coding guidance, and policy history regarding embolization of the ovarian and internal iliac veins to treat pelvic congestion syndrome.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS139NJ.O

Change TypeDefinitions and evidence/reference updates

Effective DateMar 1, 2026

Next Review Date

Key ActionVerify state-specific benefit and contractual requirements before applying this New Jersey–only policy.

SourceLink

POLICY UPDATE CHANGES

Updated definitions for Internal Iliac Vein (Hypogastric Vein) and Ovarian Vein; updated Clinical Evidence and References sections; archived previous policy version CS139NJ.N.

1Coverage stance (not medically necessary)

37241Key referenced CPT code

MultipleCited evidence sources

Coverage Summary

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.

Subject: Embolization of ovarian and internal iliac veins for pelvic congestion syndrome. Coverage stance: Not medically necessary (unproven) / not_covered_cosmetic. Scope: UnitedHealthcare Community Plan medical policy for New Jersey only that defines coverage stance, rationale, definitions, evidence, applicable coding guidance, and policy history regarding embolization of the ovarian and internal iliac veins to treat pelvic congestion syndrome. Effective date / Last review: March 1, 2026.

Pelvic Congestion Syndrome (PCS) is chronic noncyclic pelvic pain associated with pelvic varices. Embolization is an interventional radiology approach intended to occlude ovarian and/or internal iliac veins (using coils, sclerosants, plugs, gelatin sponges, etc.) to reduce venous hypertension and symptoms; however, embolization of the ovarian or internal iliac vein is considered unproven and not medically necessary due to insufficient evidence of efficacy.

Key Policy Facts

Effective dateMarch 1, 2026

Last reviewMarch 1, 2026

Policy numberCS139NJ.O

PayerUnitedHealthcare Community Plan (New Jersey)

ScopeUnitedHealthcare Community Plan medical policy for New Jersey only that defines coverage stance, rationale, definitions, evidence, applicable coding guidance, and policy history regarding embolization of the ovarian and internal iliac veins to treat pelvic congestion syndrome.

Coverage stanceEmbolization of the Ovarian Vein or Internal Iliac Vein for treating Pelvic Congestion Syndrome is unproven and not medically necessary due to insufficient evidence of efficacy.

Medical Necessity / Coverage Rationale

Coverage Rationale / Medical Necessity

Embolization of the Ovarian Vein or Internal Iliac Vein is considered:

Embolization of the Ovarian Vein or Internal Iliac Vein for treating Pelvic Congestion Syndrome is unproven and not medically necessary due to insufficient evidence of efficacy.

The determination reflects a limited, heterogeneous, and largely low-quality evidence base with uncertainties about long-term efficacy and potential effects on reproductive health. Systematic reviews and observational studies report symptom improvement for some individuals but are limited by study design, short follow-up, and inconsistent outcome measures, and additional well-designed randomized trials are needed.

Coding

Referenced CPT guidance / procedure code mentionedCPT

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)

Coding guidance: do not use CPT 37241 to report treatment of incompetent lower extremity veins; for sclerosis or endovenous ablation of incompetent extremity veins, use CPT codes 36468–36479. Verify state-specific benefit and contractual requirements before applying this policy.

Provider Actions & Billing Notes

Documentation Required

State scope

Policy applies only to New Jersey; verify state-specific benefit and contractual requirements before applying this policy.

Verify state-specific benefit and contractual requirements prior to application

Billing Rule

Coding clarification for embolization reporting

Do not use CPT 37241 to report treatment of incompetent extremity veins; see CPT 36468-36479 for sclerosis or endovenous ablation of incompetent extremity veins.

Affected codes: 37241, 36468, 36469, 36470, 36471, 36472, 36473, 36474, 36475, 36476, 36477, 36478, 36479
Do not use CPT 37241 to report treatment of incompetent extremity veins; see CPT 36468-36479

Background, Evidence, & Definitions

Pelvic Congestion Syndrome (PCS), also known as pelvic venous incompetence or ovarian vein reflux, causes noncyclic pelvic pain and discomfort lasting at least 6 months and typically affects women of reproductive age. Varicosities of the ovarian veins and/or internal iliac veins are believed to lead to PCS. Embolization therapy involves venography to visualize affected veins, catheter-directed delivery of inert embolic agents (for example, metal coils, sclerosing agents, gelatin sponges) under fluoroscopic guidance to occlude the vein, and rerouting blood flow to reduce venous pressure; embolic agents may be temporary or permanent, and embolization of internal iliac vein branches may be necessary when veins are in close proximity.

Evidence	Key findings
Systematic review (Hanna et al. 2024)
25 studies (n=2,038); most studies showed statistically significant VAS pain reduction; technical success ~94%; complications mostly self-limiting; heterogeneity and low-quality evidence limiting conclusions.
Hayes HTA (2020, updated 2023)
Low-quality evidence: many individuals improve after embolization but very limited comparative data and short follow-up (mostly ≤1 year); reported complication rates 3.8%–22%.
Karakaya et al. (2025)
Retrospective study (n=81) showed symptom reduction (VAS and other measures) but significant decrease in AMH suggesting possible impact on ovarian reserve; authors recommend further study due to uncertainties.

Term	Definition
Embolization
A procedure that uses particles, such as tiny gelatin sponges or beads, to block a blood vessel. Embolization may be used to stop bleeding or to block the flow of blood to a tumor or abnormal area of tissue (National Cancer Institute).
Internal Iliac Vein (Hypogastric Vein)
One of the principal venous tributaries that is located in the pelvis; it drains deoxygenated blood from pelvic organs and receives blood from middle rectal, pudendal, obturator, and vesical veins.
Ovarian Vein
One of a pair of veins that emerges from the broad ligament near the ovaries and the uterine tubes and carries deoxygenated blood from the ovaries (Mosby's Pocket Dictionary).
Pelvic Congestion Syndrome
A syndrome involving chronic pelvic pain that is usually associated with the varices or varicosities in the pelvic area (Merck Manual).