Highmark Commercial Medical Policy - Pennsylvania
Medical Policy: S-172-014
Topic: Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome
Section: Surgery
Effective Date: September 18, 2017
Issue Date: July 23, 2018
Last Reviewed: July 2018

Pelvic congestion syndrome (PCS also known as pelvic venous incompetence (PVI)  is a condition that has been present for greater than 6 months with anatomic findings that include pelvic  venous insufficiency and pelvic varicosities. 

The technique of transcatheter embolization for ovarian and pelvic varices is a minimally invasive treatment usually performed by an interventional radiologist that involves selective catheterization of the ovarian and internal iliac veins, followed by contrast venography and embolization.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Ovarian and internal iliac vein embolization as treatment for pelvic congestion syndrome is considered experimental/investigational, and therefore non-covered. The published data regarding embolization therapy for pelvic congestion syndrome are inadequate to permit scientific conclusions, due to the lack of standardized diagnostic criteria for pelvic congestion and the lack of controlled trials of embolization therapy. 

Procedure Codes
37241


Place of Service: Inpatient/Outpatient

Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer: If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.