CurrentUnitedHealthcarePolicy CS139OH.D

Embolization Ovarian Iliac Veins Pelvic Congestion Syndrome Oh Cs

UnitedHealthcare Ohio-specific medical policy that governs coverage determination for embolization of the ovarian and internal iliac veins to treat Pelvic Congestion Syndrome (PCS), including definitions, applicable coding guidance, clinical evidence summary, and policy history.

Policy Summary

PayerUnitedHealthcare

PolicyEmbolization Ovarian Iliac Veins Pelvic Congestion Syndrome Oh Cs

Policy CodePolicy CS139OH.D

Change TypeDefinitions, Codes, Supporting Information, Archived prior version

Effective DateJul 1, 2025

Next Review Date

Key ActionFor Ohio members, evaluate requests for services stated as unproven or subject to coverage/quantity limits using Ohio Administrative Code 5160-101 and document adherence to OAC requirements.

SourceLink

POLICY UPDATE CHANGES

Definitions: Updated definition of 'Embolization'.

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

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

Archived previous policy version CS139OH.C.

1Primary Coverage Stance (not medically necessary)

1Referenced CPT codes

3ICD-10 codes removed in revision

Coverage Summary

Policy statement regarding medical necessity: 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.

Policy metadata

Policy NumberCS139OH.D

SubjectEmbolization of Ovarian and Internal Iliac Veins for Pelvic Congestion Syndrome

ScopeUnitedHealthcare Ohio-specific medical policy (Ohio only).

Effective DateJuly 1, 2025

StatusCURRENT

Medical Necessity Criteria

Coverage Rationale

Policy statement regarding medical necessity:

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.

Application

Scope of policy:

This Medical Policy only applies to the state of Ohio.

Any requests for services stated as unproven or services with a coverage or quantity limit will be evaluated for medical necessity using Ohio Administrative Code 5160-101.

Provider Actions & Billing Notes

Documentation Required

State-specific medical necessity evaluation

For Ohio members, requests for services that are stated as unproven or that are subject to coverage or quantity limits must be evaluated for medical necessity using the Ohio Administrative Code (OAC) 5160-101. Document in the medical record that Ohio Administrative Code 5160-101 was used to evaluate the request and that the policy applies only to the state of Ohio.

Policy applies only to the state of Ohio (OAC applicability).
Evaluate and document medical necessity per Ohio Administrative Code 5160-101.

Billing Rule

Coding clarification for CPT 37241

Use CPT code 37241 for venous embolization or occlusion (venous, other than hemorrhage). Do not use CPT 37241 to report treatment of incompetent lower extremity veins. For sclerosis or endovenous ablation of incompetent extremity veins, report the appropriate codes in the 36468–36479 range per AMA/CPT guidance.

Coding

Referenced CPT Procedure CodeCPT

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)

Removed ICD-10 Diagnosis Codes (per revision history)ICD-10

I86.2
N94.89
R10.2

Background, Evidence Summary & Definitions

Pelvic Congestion Syndrome (PCS) is chronic noncyclic pelvic pain associated with pelvic venous varices and venous incompetence; symptoms typically persist for at least 6 months and predominantly affect women of reproductive age. Embolization of the ovarian and/or internal iliac veins is an endovascular technique in which, after venography, an interventional radiologist advances a catheter under fluoroscopy and deploys embolic agents (for example, metal coils, sclerosing agents, gelatin sponges) to occlude targeted veins so blood flow is rerouted and venous pressure is reduced.

The evidence base for ovarian and internal iliac vein embolization for PCS consists mainly of small uncontrolled case series, several systematic reviews, some retrospective and prospective cohort studies, limited randomized data, and single-center observational studies. While many studies report reductions in pain scores and high technical success rates, the overall quality of evidence is low and heterogeneous, with limitations including retrospective designs, small sample sizes, variable outcome measures and follow-up, and inconsistent comparative data.

Evidence	Key findings
Systematic review (Hanna et al. 2024)	25 studies (2,038 participants); most studies reported statistically significant reduction in VAS pain post-procedure; 17 studies reported symptom recurrence 0–42%; technical success ≈94%; most complications (89%) self-limited; heterogenous study designs and limited comparative data
Hayes HTA (2020, updated 2023)	Low-quality evidence that most individuals improve after embolization or sclerotherapy; very limited comparative data; most studies ≤1 year follow-up; complication rates ranged 3.8%–22%
Single-center retrospective (Smak Gregoor 2023)	75 embolizations: 20% complete improvement, 50.6% partial improvement, 26.6% no improvement; ~20% recurrence at ~13 months; retrospective design and lack of objective outcomes

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.

Internal Iliac Vein (Hypogastric Vein): The primary artery supplying the pelvic viscera and an important contributor to structures of the pelvic wall, perineum, gluteal region, and thigh.

Ovarian Vein: One of a pair of veins that emerge from the broad ligament near the ovaries and the uterine tubes.

Pelvic Congestion Syndrome (PCS): A syndrome involving chronic pelvic pain usually associated with varices or varicosities in the pelvic area.

Revision History

07/01/2025revisedLatest

Definitions: Updated definition of 'Embolization'.

07/01/2025removedLatest

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

07/01/2025revisedLatest