ModifiedUnitedHealthcarePolicy CS139ID.C

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

This medical policy governs the use and coverage stance for embolization of the ovarian vein or internal iliac (hypogastric) vein to treat Pelvic Congestion Syndrome for Idaho members, including Idaho Medicaid Plus plans.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS139ID.C

Change TypeDefinitions and references updatedmaterial changes

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionDo not approve prior authorization for ovarian or internal iliac vein embolization for Pelvic Congestion Syndrome for Idaho members because the procedure is considered not medically necessary.

SourceLink

POLICY UPDATE CHANGES

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

Instruction to refer to the Idaho Medicaid Provider Handbook for additional information on non-covered and excluded services.

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

2,038combined individuals in review

94%technical success

183reported complications

3.8%-22%

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complication rate range

75%early substantial pain relief

3policy history entries

Coverage Criteria — Embolization for Pelvic Congestion Syndrome

Unproven / Not Medically Necessary

Not covered — stance and rationale

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

Policy applies to Idaho members including Idaho Medicaid Plus plans.

This policy applies only to the state of Idaho, including Idaho Medicaid Plus plans. Within that scope, embolization of the ovarian vein or internal iliac (hypogastric) vein for Pelvic Congestion Syndrome is assigned a coverage stance of not medically necessary due to insufficient evidence of efficacy; the policy rationale and denial criteria are specific to Idaho members and Idaho Medicaid Plus enrollees.

For information about non‑covered or excluded services that may affect claims or billing, providers should refer to the Idaho Medicaid Provider Handbook, General Information and Requirements for Providers: Non‑Covered and Excluded Services, as noted in the Applicable Codes/Policy History section of this policy.

Embolization of the ovarian vein or internal iliac (hypogastric) vein for the treatment of Pelvic Congestion Syndrome (PCS) is considered unproven and not medically necessary because available evidence is insufficient to demonstrate clinical efficacy.

Coding and Related Clinical Details

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

Applicable Codes (see Idaho Medicaid Provider Handbook)mixed

No codes listed

Duration of symptoms required for PCS

Duration of symptomsAt least 6 months of noncyclic pelvic pain consistent with Pelvic Congestion Syndrome

Typical patient populationUsually affects women of reproductive age

Context for interventionSymptoms persistent despite conventional treatments (e.g., pharmacologic therapy, surgical intervention) may prompt consideration of embolization in investigational settings

Fluoroscopy safety reference

Fluoroscopy safety guidanceRefer to U.S. Food and Drug Administration fluoroscopy guidance for imaging radiation considerations

Source access

Provider Actions, Authorization, and Documentation

Prior Authorization

Prior Authorization and Applicability

This policy applies to UnitedHealthcare members in the state of Idaho, including Idaho Medicaid Plus plans. Prior authorization requirements and benefit determinations may vary by plan and state contract — verify Idaho-specific prior authorization rules before scheduling or performing embolization procedures.

Applies to Idaho members, including Idaho Medicaid Plus

Denial Risk

Coverage Rationale — Denial Risk

Embolization of the ovarian vein or internal iliac vein for Pelvic Congestion Syndrome is considered unproven and not medically necessary based on available evidence. Denial of coverage may be issued when embolization is requested for PCS.

Embolization for PCS is unproven/not medically necessary

Background — Pelvic Congestion Syndrome and Context

Pelvic Congestion Syndrome (PCS) is characterized by chronic, noncyclic pelvic pain often associated with pelvic venous varices and typically occurs in women of reproductive age. Endovascular embolization procedures target incompetent pelvic veins (for example, the ovarian or internal iliac veins) with coils, sclerosants, or other occlusive agents to reduce venous congestion, but evidence supporting symptom improvement and long‑term benefit is limited; for that reason, embolization for PCS is not considered medically necessary under this policy.

Definitions

Embolization

DefinitionEmbolization: an endovascular procedure that uses particles or agents (e.g., tiny gelatin sponges, beads, metal coils, or sclerosing agents) to occlude a blood vessel to stop bleeding or block flow to abnormal tissue

Typical materialsCommon embolic agents include metal coils, sclerosing agents, and gelatin sponges; agents may be temporary or permanent

Typical use in PCSUnder fluoroscopic guidance, a catheter is advanced to the affected ovarian or internal iliac vein and inert embolic agents are deployed to seal the vein and reroute blood flow

Internal Iliac Vein (Hypogastric Vein)

Anatomical roleInternal Iliac Vein (Hypogastric Vein): a principal venous tributary located in the pelvis that drains deoxygenated blood from pelvic organs

Tributaries

Revision History

2026-06-01Definitions updatedLatest

Updated definitions for Internal Iliac Vein (Hypogastric Vein) and Ovarian Vein; previous policy version CS139ID.B archived.

2026-06-01Applicable codes updated

Added instruction to refer to the Idaho Medicaid Provider Handbook for information on non-covered and excluded services.

2026-06-01Supporting information updated

Clinical evidence and references sections updated to reflect the most current information.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS139ID.C

Change TypeDefinitions and references updatedmaterial changes

Effective DateJun 1, 2026

Next Review DateN/A

SourceLink

On This Page

FDA fluoroscopy guidance available at the FDA website for Radiation-Emitting Products: Medical X-ray Imaging/Fluoroscopy

Clinical implicationFollow FDA recommendations to minimize radiation exposure during venography and fluoroscopically guided embolization procedures

Note

Benefit Contract and State Requirements

Before providing services, check the member’s benefit contract and any applicable federal or state requirements. Federal, state, or contractual requirements govern when they conflict with this policy. For additional details on non-covered and excluded services, refer to the Idaho Medicaid Provider Handbook: General Information and Requirements for Providers: Non-Covered and Excluded Services.

Benefit determinations governed by federal/state/contractual requirements
Refer to Idaho Medicaid Provider Handbook for non-covered/excluded services

Documentation Required

Required Documentation and Coding Clarification

Document the medical necessity for embolization thoroughly: include the diagnosis (Pelvic Congestion Syndrome or related ICD-10 diagnosis), radiologic confirmation (venography/imaging demonstrating ovarian or internal iliac vein varicosities or reflux), prior conservative therapies tried and their durations, and procedure rationale. Use CPT coding consistent with AMA guidance: CPT 37241 pertains to venous embolization/occlusion (venous, other than hemorrhage) and should not be used for treatment of incompetent extremity veins (see CPT codes 36468-36479 for extremity procedures). Inclusion of a code in this policy does not guarantee coverage or reimbursement.

Document diagnosis and radiologic confirmation (venography/imaging)
Document prior conservative therapies and durations
Coding note: CPT 37241 = venous embolization/occlusion (not for incompetent extremity veins); see 36468-36479 for extremity treatments

Note

Conservative Therapy Context

Conservative therapies (e.g., pharmacologic pain management, physical therapy, or surgical alternatives) are customary first-line treatments for PCS. Embolization is an investigational option for individuals who have not adequately responded to conventional management; document attempts and response to conservative treatments prior to considering embolization.

Conservative therapies should be attempted and documented prior to embolization
Embolization considered investigational when prior therapies fail

Note

Plan Documentation and Decision Support

UnitedHealthcare may use third-party decision-support tools (for example, InterQual) to assist in benefit administration. Refer to plan documentation and applicable utilization management tools when submitting requests for services to ensure required criteria and documentation are met.

Plans may use InterQual or similar tools to assist decisions
Check plan-specific documentation and utilization management requirements when submitting requests

Receives blood from middle rectal veins, pudendal veins, obturator veins, and inferior and superior vesical veins

Clinical relevanceServes as a main pathway for venous drainage of pelvic structures and may be a target for embolization when varicosities contribute to PCS

Ovarian Vein

Anatomical descriptionOvarian Vein: one of a pair of veins that emerges from the broad ligament near the ovaries and uterine tubes and carries deoxygenated blood from the ovaries

LocationRuns from the ovary toward the pelvic venous system and can develop varicosities implicated in PCS

Clinical relevanceOvarian vein reflux or varicosities are believed to contribute to Pelvic Congestion Syndrome and may be visualized by venography prior to embolization

Pelvic Congestion Syndrome

Syndrome definitionPelvic Congestion Syndrome: chronic noncyclic pelvic pain usually associated with pelvic varices or varicosities, typically lasting at least 6 months

Typical etiologyVaricosities of the ovarian veins and/or internal iliac veins leading to venous hypertension and pelvic pain

Treatment contextConsidered in patients who have persistent symptoms despite conventional treatments; embolization is investigational for PCS due to limited evidence

Internal Iliac Vein (Hypogastric Vein) — revised

Updated definition textInternal Iliac Vein (Hypogastric Vein): principal venous tributary in the pelvis that drains deoxygenated blood from pelvic organs; updated in policy revision (06/01/2026)

Revision noteDefinition updated and previous version archived (CS139ID.B)

Clinical implicationRevised wording clarifies the vein's role in pelvic venous drainage relevant to embolization discussions

Ovarian Vein — revised

Updated definition textOvarian Vein: one of a pair of veins emerging from the broad ligament near the ovaries and uterine tubes that carries deoxygenated blood from the ovaries; definition updated in the 06/01/2026 policy revision

Revision noteDefinition updated and previous version archived (CS139ID.B)

Clinical implicationClarified anatomical description to support policy references to ovarian vein embolization