ModifiedUnitedHealthcarePolicy CS139OH.D

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

This policy governs coverage for ovarian vein and internal iliac vein embolization to treat pelvic congestion syndrome for UnitedHealthcare members in Ohio.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS139OH.D

Change TypeDefinitions updatedICD-10 codes removedreferences revised

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis, prior conservative therapies, venography findings, and procedural details when requesting embolization in Ohio.

SourceLink

POLICY UPDATE CHANGES

Applicable Codes Removed list of ICD-10 diagnosis codes: 186.2, N94.89, and R10.2.

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

Definitions Updated definition of "Embolization".

Ohio-onlyJurisdiction

InsufficientEvidence quality

94%Technical success

3ICD-10 codes removed

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Coverage Determinations and Rationale

Not Medically Necessary — Embolization for Pelvic Congestion Syndrome

Covered when ALL of the following are met:

Not Medically Necessary

The procedure is embolization of the ovarian vein or internal iliac veins specifically for the diagnosis of pelvic congestion syndrome (PCS).
There is high‑quality, peer‑reviewed evidence demonstrating clinical benefit (randomized controlled trials or equivalent) showing efficacy and acceptable safety for the intended population.
No such evidence currently exists in the literature.
The indication is consistent with applicable benefit plan language and regulatory requirements for the member’s coverage.

"",""

Denial Risk

Prior Authorization Required / Denial Risk

Prior authorization is required and services may be denied as not medically necessary. Providers must document clinical rationale, prior conservative therapies, and how the requested service meets applicable benefit plan rules and regulatory requirements. Failure to provide required documentation or lack of evidence of plan‑covered indication may result in denial.

Prior authorization required: submit clinical records showing prior conservative management and symptom chronology.
Document applicable benefit rules and member coverage for procedural indications.
Ensure compliance with federal and state regulatory requirements for the procedure and facility credentialing.

Applicable Codes and Coding Notes

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

Removed ICD-10 Diagnosis CodesICD-10

186.2	ICD-10 diagnosis code (removed)
N94.89	ICD-10 diagnosis code (removed)
R10.2	ICD-10 diagnosis code (removed)

Duration of symptoms

Required duration of symptomsSymptoms lasting >= 6 months

Clinical contextNoncyclic pelvic pain and discomfort lasting at least 6 months, typically affecting women of reproductive age

Relation to PCS diagnosisDuration aligns with description of Pelvic Congestion Syndrome in policy clinical background

Prior Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Ohio prior authorization requirement

Requests for ovarian or internal iliac vein embolization in Ohio will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01 and applicable plan rules; submit prior authorization consistent with Ohio-specific requirements.

Prior Authorization

Source of prior authorization criteria

Prior authorization and medical necessity determinations follow UnitedHealthcare standard benefit plans and may use InterQual criteria; when InterQual is not applicable, UnitedHealthcare Medical Policies/Guidelines may be used.

Step Therapy

Conservative therapy prerequisite

Embolization is described as an investigational option for individuals who fail to respond to conventional treatments such as pharmacologic therapy or surgical intervention; document prior conservative therapies attempted.

Clinical Background and Condition Summary

Pelvic Congestion Syndrome (PCS), also referred to as pelvic venous incompetence or ovarian vein reflux, is characterized by chronic noncyclic pelvic pain lasting at least 6 months, most commonly in women of reproductive age. The syndrome is thought to be related to varicosities or reflux of the ovarian and/or internal iliac veins. Embolization is a catheter-directed procedure that uses embolic agents (for example, coils or sclerosants) under fluoroscopic guidance to occlude affected pelvic veins in an attempt to reduce venous hypertension and pain.

Definitions

Embolization

DefinitionA catheter-directed procedure that uses particles or agents (e.g., gelatin sponges, metal coils, sclerosing agents, beads) to occlude or block a blood vessel under fluoroscopic guidance

PurposeMay be used to stop bleeding or to block flow to abnormal tissue or varicose pelvic veins

Embolic agents noted in policyMetal coils, sclerosing agents, gelatin sponges; agents may be temporary or permanent

Internal Iliac Vein (Hypogastric Vein)

Policy usageReferred to as Internal Iliac Vein (Hypogastric Vein) in the policy heading

Description from sourceDescribed textually as the primary artery supplying the pelvic viscera and contributor to pelvic wall, perineum, gluteal region, and thigh structures

Policy Updates and Document Changes

2025-07-01definition_updateLatest

Updated definition of 'Embolization' in the Definitions section to clarify the procedure description.

2025-07-01codes_removed

Removed ICD-10 diagnosis codes 186.2, N94.89, and R10.2 from the Applicable Codes section.

2025-07-01supporting_information_updated

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS139OH.D

Change TypeDefinitions updatedICD-10 codes removedreferences revised

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis, prior conservative therapies, venography findings, and procedural details when requesting embolization in Ohio.

SourceLink

On This Page

Conservative therapies include pharmacologic therapy or prior surgical intervention as noted in the policy.

Step Therapy

Step therapy — not specified

No explicit step therapy requirements (ordered medication or procedural step mandates) are specified in this policy extract.

Documentation Required

Documentation supporting procedure

Include documentation that supports the medical necessity of the procedure: diagnosis of pelvic congestion syndrome, prior conservative therapies tried, venography/imaging used to visualize affected veins, and procedural details including embolic agents and targeted veins.

Diagnosis of pelvic congestion syndrome (PCS)
Records of prior pharmacologic or surgical treatments and response
Venography or imaging used to visualize affected veins
Procedure notes specifying targeted veins and embolic agents

Documentation Required

Document applicable benefit rules

Verify and document applicability of federal, state (Ohio Administrative Code), and contractual benefit plan requirements when submitting claims and authorization requests.

Note

Regulatory/contractual compliance affects coverage

Coverage determinations must reference federal, state (Ohio Administrative Code), or contractual requirements; where conflicts exist, those requirements govern and may affect coverage or trigger denial if not met.

Clinical notePolicy notes that internal iliac veins are in close proximity to ovarian veins and may also be targeted during embolization

Ovarian Vein

Anatomical definitionA pair of veins that emerge from the broad ligament near the ovaries and the uterine tubes

Role in PCSVaricosities of the ovarian veins are believed to contribute to pelvic congestion syndrome

Procedure relevanceOvarian vein embolization is performed after venography to visualize affected veins

Pelvic Congestion Syndrome (PCS)

Syndrome definitionA syndrome involving chronic pelvic pain, usually associated with varices or varicosities in the pelvic area

Clinical durationPain is noncyclic and typically lasts at least 6 months

Affected populationTypically affects women of reproductive age

Embolization (updated)

Updated definition summaryPolicy definition of 'Embolization' revised (see Policy History/Revision Information) to reflect current wording in Definitions section

Source languageEmbolization: A procedure that uses particles, such as gelatin sponges or beads; to block a blood vessel; may be used to stop bleeding or to block the flow of blood to a tumor or abnormal area of tissue

Clinical application notePolicy indicates embolic agents used may be inert coils, sclerosing agents, or gelatin sponges and may be temporary or permanent

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

Revision note: Coverage determinations must follow applicable federal, state (Ohio Administrative Code), or contractual benefit plan requirements. Where those rules differ from this Medical Policy, the federal, state (OAC), or contractual requirements govern and should be documented when requesting coverage or submitting claims.