Aetna considers ovarian vein embolization medically necessary for the treatment of pelvic congestion syndrome (PCS) when both of the following criteria are met:
Aetna considers ovarian vein embolization for the treatment of PCS experimental and investigational when criteria are not met.
Aetna considers sclerotherapy in the treatment of pelvic congestion syndrome experimental and investigational because the clinical evidence is not sufficient to permit conclusions on the health outcome effects of sclerotherapy in the treatment of pelvic congestion syndrome.Background
Pelvic congestion syndrome (PCS, also known as pelvic venous incompetence [PVI]), a condition associated with ovarian vein incompetence, is manifested by pelvic pain of variable intensity, that is heightened before or during menses and that is aggravated by prolonged standing, fatigue and intercourse. Laparoscopic and venographic evidence of varicosities confirm the diagnosis of PCS. The traditional therapy for PCS includes both medical approaches (e.g., dihydroergotamine, ovarian suppression, and rheologic agents) and surgical approaches (e.g., hysterectomy, uterine ventro-suspension, ovarian vein ligation, and excision).
Ovarian vein embolization is a minimally invasive treatment alternative for PCS. The technique, usually performed by an interventional radiologist, involves threading a catheter, guided by X-ray imaging, through the groin to the ovarian veins. If the imaging reveals a cluster of serpentine veins, tiny stainless steel coils and/or absorbable sponges, or liquids such as glue are passed through the catheter into the ovarian vein, forming a clot that subsequently blocks the accumulation of blood in the varices. Careful selection of patients and use of appropriate angiographic and technical skills by the interventional radiologist are requisite for the success of this therapeutic alternative.
Chung and Huh (2003) assessed the effectiveness of various treatments for PCS in patients with different stress levels. These investigators analyzed 106 patients with PCS confirmed with laparoscopy and venography, who did not respond to medication after 4 to 6 months medication. They were divided into 3 groups: (i) embolotherapy; (ii) hysterectomy with bilateral oophorectomy and hormone replacement therapy; and (iii) hysterectomy with unilateral oophorectomy. The visual analog scale was used to measure degree of pain; stress level data were scored with the revised social readjustment rating scale. Embolotherapy was significantly more effective at reducing pelvic pain, compared to the other methods (p < 0.05). The mean percentage decrease in pain was significantly greater in the patients with lower stress scores (p < 0.05). The authors concluded that ovarian and/or internal iliac vein embolization appears to be a safe, well-tolerated, effective treatment for PCS that has not responded to medication.
Smith (2012) stated that PCS is one of many causes of chronic pelvic pain. It is generally accepted that this is attributable to ovarian and pelvic vein incompetence that may result in varices in the lower limb leading to presentation in varicose vein clinics. However, far more patients have pelvic varices associated with varicose veins in the lower limb than have PCS. Magnetic resonance imaging and computed tomographic venography are usually used in the diagnosis of this condition and criteria have been established to identify pelvic varices. Many different treatments have been used to manage the symptoms of pelvic congestion. Hysterectomy combined with oophrectomy, open surgical ligation of ovarian veins and laparoscopic vein ligation have been used in the past. The most common treatments used currently involve embolization of pelvic and ovarian veins. The results of this treatment have been published in a limited number of clinical series, usually with fairly short follow-up periods. These treatments may be complicated by migration of embolization of coils used to occlude veins. The longest duration of follow-up currently reported is 5 years. Limited clinical evidence supports the use of embolotherapy in the management of PCS.
|CPT Codes / HCPCS Codes / ICD-9 Codes|
|CPT codes covered if selection criteria are met:|
|36245||Placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family|
|36246||placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family|
|36247||placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family|
|+ 36248||selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate)|
|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 (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)|
|75894||Transcatheter therapy, embolization, any method, radiological supervision and interpretation|
|75898||Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion, other than for thrombolysis|
|Other HCPCS codes related to the CPB:|
|J1110||Injection, dihydroergotamine mesylate, per 1 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J9202||Goserelin acetate implant, per 3.6 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9219||Leuprolide acetate implant, 65 mg|
|S0132||Injection, ganirelix acetate, 250 mcg|
|ICD-9 codes covered if selection criteria are met:|
|625.5||Pelvic congestion syndrome|
|CPT codes not covered if selection criteria are met:|
|36012||Selective catheter placement, venous system; second order, or more selective, branch (eg, left adrenal vein, petrosal sinus)|
|ICD-9 codes not covered for indications listed in the CPB:|
|625.5||Pelvic congestion syndrome|