ModifiedUnitedHealthcarePolicy CS139LA.L

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

Policy governing use and coverage of ovarian and internal iliac vein embolization to treat pelvic congestion syndrome for members in Louisiana; addresses medical necessity and evidence review.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS139LA.L

Change TypeDefinitions updatedICD-10 codes removedevidence section refreshed

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionVerify plan-specific prior authorization requirements against the member's contract before submitting requests for embolization procedures.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Embolization'.

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

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

Insufficientbody of evidence quality

25 studiessystematic review sample

94%technical success

0–42%symptom recurrence

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.

3.8%–22%complication rate range

3ICD-10 codes removed

Coverage Criteria

Not Medically Necessary

Covered when ALL of the following are met:

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

Applies to members in Louisiana only.

This policy applies only to members in the state of Louisiana. For those members, embolization of the ovarian vein or internal iliac (hypogastric) vein for Pelvic Congestion Syndrome (PCS) is considered unproven and not medically necessary due to insufficient evidence of efficacy.

This Medical Policy is provided for informational purposes to assist interpretation of UnitedHealthcare standard benefit plans and does not constitute medical advice. Always reference the applicable federal, state, or contractual benefit plan terms before making coverage decisions, as those requirements govern in the event of a conflict.

Embolization of the ovarian vein or internal iliac vein for the treatment of Pelvic Congestion Syndrome is considered unproven and not medically necessary because the available evidence does not demonstrate sufficient efficacy.

Coding and Documentation

Applicable / referenced 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 (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)

Previously listed ICD-10 diagnosis codes (removed)ICD-10

I86.2	ICD-10 diagnosis code removed from policy
N94.89	ICD-10 diagnosis code removed from policy
R10.2	ICD-10 diagnosis code removed from policy

inv-07: Duration of symptoms — at least 6 months

Required symptom durationSymptoms of pelvic pain or discomfort must have lasted at least 6 months to meet the policy's duration threshold.

Typical patient populationUsually affects women of reproductive age presenting with noncyclic pelvic pain lasting ≥6 months.

Relation to PCS diagnosisDuration criterion aligns with description of Pelvic Congestion Syndrome as noncyclic pelvic pain lasting at least 6 months.

Provider Actions & Billing Guidance

Documentation Required

Provider coding reference — CPT 37241 and documentation note

Coding Clarification: According to the American Medical Association (AMA), CPT code 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; for sclerosis or endovenous ablation of incompetent extremity veins, refer to CPT codes 36468-36479. The listing of codes in this policy is for reference only and does not guarantee coverage or payment.

37241 — Vascular embolization or occlusion, venous (inclusive of radiological supervision/interpretation and imaging guidance)
For incompetent extremity veins: CPT 36468-36479

Prior Authorization

Verify plan-specific prior authorization

Verify plan-specific prior authorization and benefit terms before providing services. Coverage decisions are governed by the member's federal, state, and contractual benefit requirements and may differ from this policy.

Background

Pelvic Congestion Syndrome (PCS) is a clinical syndrome characterized by chronic, noncyclic pelvic pain often associated with varices or varicosities of the ovarian or internal iliac venous system, most commonly affecting women of reproductive age. Embolization is an endovascular procedure that occludes refluxing pelvic veins using materials such as coils, sclerosants, or gelatin sponge delivered via catheter under fluoroscopic guidance. Evidence for the long-term efficacy and safety of ovarian or internal iliac vein embolization in PCS is limited and heterogeneous, and therefore the procedure is considered investigational in this policy.

Definitions

inv-17: Embolization — definition of the procedure using particles to block a blood vessel

DefinitionA procedure that uses particles, such as tiny gelatin sponges or beads, to block a blood vessel; may stop bleeding or block flow to a tumor or abnormal tissue.

Typical agentsEmbolic agents include metal coils, sclerosing agents, gelatin sponges, and other inert materials delivered via catheter.

Procedure overviewPerformed under fluoroscopy with catheter-guided delivery of embolic material to occlude targeted pelvic veins (e.g., ovarian or internal iliac).

inv-18: Internal Iliac Vein (Hypogastric Vein) — anatomical definition

Anatomic identityInternal Iliac Vein (Hypogastric Vein) — principal vessel supplying the pelvic viscera and an important contributor to the pelvic wall, perineum, gluteal region, and thigh.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS139LA.L

Change TypeDefinitions updatedICD-10 codes removedevidence section refreshed

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionVerify plan-specific prior authorization requirements against the member's contract before submitting requests for embolization procedures.

SourceLink

On This Page

Confirm prior authorization requirements with UnitedHealthcare for the member's specific plan

Benefit language and contractual terms override this policy when conflicts exist

Documentation Required

Conservative therapy context — document prior treatments

Conservative therapy context: Embolization is being investigated for individuals who fail to adequately respond to conventional treatments. Document prior conservative management (e.g., documented trial of pharmacologic therapy and/or prior surgical interventions) and clinical rationale for proceeding to embolization.

Document duration and response to pharmacologic therapies
Document prior surgical interventions and outcomes

Documentation Required

Provider-facing documentation reminder

Provider note: Ensure all required clinical documentation is submitted to support medical necessity determinations and any prior authorization requests.

Include venography/imaging reports, symptom duration (>= 6 months), and prior treatment history
Provide procedure rationale and planned embolic agents

Billing Rule

Coding / documentation note — codes are reference only

Coding/documentation note: Listing of codes in this policy is for reference only and may not be all-inclusive. Inclusion of a code does not imply coverage, reimbursement, or guarantee of claim payment. Follow coding conventions and payer billing guidance when submitting claims.

Codes listed are informational; verify coverage and reimbursement with the member's plan
Ensure supporting documentation accompanies claims to avoid denials

Note

Claims/coverage decision guidance

Claims and coverage decision guidance: This policy aids interpretation of UnitedHealthcare standard benefit plans but does not replace review of the member's specific plan documents. UnitedHealthcare may use third-party tools (e.g., InterQual) to assist in benefit administration.

Reference the member's federal, state, and contractual benefit terms for final coverage determination
Be prepared to supply clinical evidence and documentation if claims are selected for medical review

Denial Risk

Not medically necessary — denial risk for embolization in PCS

Not medically necessary — denial risk: Embolization of the Ovarian Vein or Internal Iliac Vein for Pelvic Congestion Syndrome is considered unproven and not medically necessary due to insufficient evidence of efficacy. Submissions for this service may be denied when billed under benefit plans that follow this policy.

Denial risk if clinical documentation does not meet plan-specific exceptions or coverage criteria
If pursuing appeal, provide robust clinical evidence and rationale

Note

Benefit language governs

Benefit language governs: When there is a conflict between this policy and the member's federal, state, or contractual benefit terms, the benefit terms will govern. Check plan documents prior to service delivery.

In case of conflict, follow federal/state/contractual requirements
This policy is informational and may be modified by UnitedHealthcare

Varicosities or reflux in the internal iliac veins may contribute to Pelvic Congestion Syndrome and can be targeted during embolization procedures.

Procedure noteBecause ovarian and internal iliac veins are in close proximity, embolization of the internal iliac vein may be performed in conjunction with ovarian vein embolization when indicated.

inv-19: Ovarian Vein — anatomical definition

Anatomic identityOvarian Vein — one of a pair of veins that emerge from the broad ligament near the ovaries and the uterine tubes.

Role in PCSVaricosities or reflux of the ovarian veins are believed to contribute to Pelvic Congestion Syndrome and are common targets for embolization.

Procedure noteOvarian vein embolization is performed after venography to visualize affected veins and guide catheter-directed delivery of embolic agents.

inv-20: Pelvic Congestion Syndrome (PCS) — syndrome definition

Syndrome definitionPelvic Congestion Syndrome (PCS) — a syndrome involving chronic, usually noncyclic pelvic pain typically associated with varices or varicosities in the pelvic area.

Typical featuresChronic pelvic pain and discomfort often associated with varicosities of the ovarian and/or internal iliac veins; typically affects women of reproductive age.

Diagnostic contextPCS is associated with venous reflux and varicosities visualized on venography, which can inform consideration of embolization for refractory cases.

inv-21: Updated definition of 'Embolization' as noted in policy revisions

Revised definition noteDefinition language for 'Embolization' was updated in the policy revision dated 08/01/2025.

Scope of updateChange is recorded in Policy History/Revision Information; consult the Definitions section for the updated wording used in this version.

Implication for documentThe updated definition replaces the prior wording and is reflected in the archived previous policy version CS139LA.K.