CurrentUnitedHealthcarePolicy CS139TN.P

Embolization Ovarian Iliac Veins Pelvic Congestion Syndrome Tn Cs

State-specific UnitedHealthcare medical policy for Tennessee Medicaid and CoverKids defining coverage position for embolization of the ovarian and internal iliac veins to treat pelvic congestion syndrome (PCS), including definitions, clinical evidence summary, applicable coding guidance, and policy history.

Policy Summary

PayerUnitedHealthcare

PolicyEmbolization Ovarian Iliac Veins Pelvic Congestion Syndrome Tn Cs

Policy CodePolicy CS139TN.P

Change TypeDefinitions revised; Clinical Evidence updated

Effective DateApr 1, 2026

Next Review Date

Key ActionWhen deciding coverage, reference federal, state, or contractual benefit requirements which may supersede this policy; in case of conflict, those requirements govern.

SourceLink

POLICY UPDATE CHANGES

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

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

1Coverage stance (not medically necessary)

37241Primary referenced CPT code

Tennessee Medicaid/CoverKidsApplies to

Coverage Summary

Scope: This policy addresses Embolization of the Ovarian and Internal Iliac Veins to treat Pelvic Congestion Syndrome (PCS) for Tennessee Medicaid and CoverKids. Payer/program applicability: UnitedHealthcare medical policy for Tennessee Medicaid and CoverKids. Effective date: April 1, 2026; Last review: April 1, 2026.

Quick facts: • Coverage stance: Not medically necessary / unproven. • Primary referenced CPT code: 37241. • Applies to: Tennessee Medicaid/CoverKids.

Key facts

Coverage stanceNot medically necessary / Unproven (Embolization of ovarian or internal iliac veins for PCS)

Applies toTennessee Medicaid/CoverKids

Primary referenced CPT code37241

Policy numberCS139TN.P

Effective dateApril 1, 2026

Last reviewApril 1, 2026

Provider Actions / Billing Guidance

Documentation Required

Apply contractual/state benefit criteria

When deciding coverage, reference federal, state, or contractual benefit requirements which may supersede this policy; in case of conflict, those requirements govern.

Billing Rule

Coding clarification for CPT 37241

CPT 37241 is specific to venous embolization or occlusion and excludes lower extremity venous incompetency; do not use 37241 to report treatment of incompetent extremity veins (use 36468-36479 for endovenous ablation of incompetent extremity veins).

37241
36468
36469
36470
36471
36472
36473
36474
36475
36476
36478
36479

Background, Evidence Summary & Definitions

Pelvic Congestion Syndrome (PCS) is chronic noncyclic pelvic pain typically associated with pelvic varices or varicosities and most commonly affects women of reproductive age. Embolization is an interventional option in which an interventional radiologist uses venography and fluoroscopically guided catheter techniques to deliver embolic agents (coils, sclerosants, gelatin sponges, etc.) to occlude the ovarian and/or internal iliac veins to reduce venous pressure and relieve symptoms.

Embolization may be considered for individuals who have not adequately responded to conventional therapies, but it remains investigational in this context because the evidence base is insufficient to establish consistent benefits and risks.

Evidence summary:

• Systematic review (Hanna et al. 2024): 25 studies (2,038 individuals); most studies reported statistically significant reductions in VAS pain scores and overall technical success ~94%, but study heterogeneity and limited comparative data prevented meta-analysis.

• Hayes HTA (2020; updated 2023): Concluded the evidence is low quality; most individuals improve but comparative evidence is very limited and follow-up is often ≤ 1 year; reported complication rates ranged approximately 3.8%–22%.

• Karakaya et al. (2025): Retrospective single‑center study (n=81) showed symptom reduction but also reported a significant decrease in AMH, raising concerns about possible effects on ovarian reserve; authors called for larger, prospective studies.

Overall certainty: Evidence is low to very low in quality, heterogeneous in design, and lacks robust randomized comparative trials and long‑term outcome data.

Glossary:

• Embolization: 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.

• Internal Iliac Vein (Hypogastric Vein): Principal pelvic venous tributary that drains pelvic organs and receives blood from middle rectal, pudendal, obturator, and vesical veins.

• Ovarian Vein: One of a pair of veins arising near the ovaries that carries deoxygenated blood from the ovaries.

• Pelvic Congestion Syndrome (PCS): A syndrome of chronic pelvic pain usually associated with pelvic varices or varicosities.

Revision History

2026-04-01definitions_updatedLatest

Definitions section updated: Internal Iliac Vein (Hypogastric Vein) and Ovarian Vein definitions revised; definitions clarify embolization and PCS.

2026-04-01clinical_evidence_updatedLatest

Clinical Evidence and References sections updated to include recent systematic reviews and studies; previous policy version CS139TN.O archived.

2026-04-01policy_effective_dateLatest

Policy effective date set to April 1, 2026; applies to Tennessee Medicaid and CoverKids.

coverage_stanceLatest

Policy position: 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.