Medical Policy
Effective Date:09/01/2012 Title:Ovarian & Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
Revision Date: Document:BI367:00
CPT Code(s):37204, 37241, 37242, 37243, 37244
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

  1. Pelvic congestion syndrome is a condition of chronic pelvic pain of variable location and intensity, which is associated with dyspareunia and postcoital pain and is aggravated by standing. 
  2. Attempts have been made to treat this syndrome by embolization of the ovarian or internal iliac veins, but lack of scientific evidence prevents assessment of this treatment’s effectiveness. 
  3. This procedure is considered experimental and investigational.
Medical Statement
  1. Embolization of the ovarian vein and internal iliac veins is considered experimental and is not covered.
  2. For other uses of embolization see BI301

 

Codes Used in this BI:

37204

Transcatheter occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method, non-central nervous system, non-head or neck (Code deleted & replaced by 37241, 37242, 37243, 37244 eff 1-1-2014)

37241

Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road-mapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage(eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)

37242

..arterial, other than hemorrhage or tumor(eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms)

37243

..for tumors, organ ischemia, or infarction

37244

..for arterial or venous hemorrhage or lymphatic extravasation
Limits
Intentially left empty
Reference

Cordis PR, Eclavea A, et al.(1998) Pelvic congestion syndrome: Early clinical results after transcatheter ovarian vein embolization. J Vasc Surg 1998; 28:862-68.

Gandidn R, Chiocchi M, et al.(2008) Transcatheter foam sclerotherapy of symptomatic female varicocele with sodium tetradecyl-sulfate foam. Cardiovasc Intervent Radiol, 2008; 31(4):778-84.2007

Ganeshan A, Upponi S, et al.(2007) Chronic pelvic pain due to pelvic congestion syndrome: the role of diagnostic and interventional radiology. Cardiovasc Intervent Radiol, 2007; 30:1105-11.

Kim HS, Malhotra AD, et al.(2006) Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol, 2006; 17(2 Pt 1):289-97.

Kwon SH, Oh JH, et al.(2007) Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome. Cardiovasc Intervent Radiol, 2007; 30(4):655-61.

Liddle AD, Davies AH.(2007) Pelvic congestion syndrome: chronic pelvic pain caused by ovarian and internal iliac varices. Phlebology, 2007; 22(3):100-4.

Maleux G, Stockx L, et al.(2000) Ovarian vein embolization for the treatment of pelvic congestion syndrome: Long term technical and clinical results. J Vasc Interven Radiol 2000; 11:859-64.

Naoum JJ.(2009) Endovascular therapy for pelvic congestion syndrome. Methodist Debakey Cardiovasc J 2009; 5(4):36-8.

Nicholson T, Basile A.(2006) Pelvic congestion syndrome: who should we treate and how? Tech Vasc Interv Radiol, 2006; 9(1):19-23.

Shokeir T, Amr R, Abdelshaheed M.(2009) The efficacy of Implanon for the treatment of chronic pelvic pain associated with pelvic congestion: 1-year randomized controlled pilot study. Arch Gynecol Obstet, 2009; Feb 4 [Epub ahead of print].
Sichlau MU, Yao JST, et al.(1994) Transcatheter embolotherapy for the tratment of pelvic congestion syndrome. Obstet Gynecol 1994; 83:892-96.

Stones RW.(2003) Pelvic vascular congestion - Half a century later. Clin Obstet Gynecol 2003; 46:831-36.

Tarazov PB, Prozorovakji KV, et al.(1997) Pelvic pain syndrome caused by ovarian varices: treatment of transcatheter embolization. Acta Rad 1997; 98:1023-25.

Tropeano G, Di Stasi C, et al.(2008) Ovarian vein incompetence: a potential cause of chronic pelvic pain in women. Eur J Obstet Gynecol Reprod Biol, 2008; 139(2):215-21.

Venbrux AC, Chang AH, et al.(2002) Pelvic congestion syndrome (pelvic venous incompetence): Impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J Vas Inter Radilo 2002; 13:171-78.

Venbrux AC, Lambert DL.(1999) Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence (pelvic congestion syndrome). Curr Opin Obstet Gynecol 1999; 11:395-99.

 
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.