Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome

Policy #:11.06.07d

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Ovarian and internal Iliac vein embolization as a treatment for pelvic congestion syndrome is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, ovarian and internal iliac vein embolization as a treatment for pelvic congestion syndrome is not eligible for payment under the medical benefits of the Company’s products because the service is considered experimental/investigational and, therefore, not covered.

Services that are experimental/investigational are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

Description

Pelvic congestion syndrome is theorized to be caused by malfunctioning ovarian veins that allow blood to flow backward, away from the heart, which then pools and builds pressure. The stretching and bulging of the veins (known as varices) leads to pain and other symptoms due to the dilatation and congestion in the veins. Pelvic congestion syndrome typically affects women during the reproductive years and is frequently a diagnosis of exclusion. Identification of the varices can be made by magnetic resonance imaging (MRI), computed tomography (CT) scanning, contrast venography, or direct visualization. An interventional radiologist may treat this condition by blocking the abnormal veins through the use of a balloon catheter, steel coil, and/or sclerosing solution. The technique involves selectively catheterizing the ovarian and internal iliac veins and advancing the catheter into the abnormal vein. The abnormal vein is then blocked at its source, which is theorized to decrease congestion and relieve symptoms.

The majority of available published peer-reviewed literature are case series for individuals receiving this therapy. Laborda et al evaluated the clinical outcome and patients’ satisfaction during a 5 year follow-up period for pelvic congestion syndrome. Limitations for this study, however, include the lack of clearly defined diagnostic criteria, as well as the absence of a control group to compare outcomes. A 2016 systematic review by Mahmoud et al identified 20 case series (total N=1081 patients) who underwent vein embolization for pelvic congestion syndrome. The authors did not require any particular diagnostic criteria for pelvic congestion syndrome. The length of follow-up in the studies ranged from 1 month to 6 years. Seventeen studies (n=648 patients) reported the proportion of patients who reported symptom relief. Overall, 571 (88.1%) patients reported short-term symptom relief and 77 (11.9%) reported little or no relief. Seventeen studies (n=721 patients) reported symptom relief at 12 months. A total of 88.6% had symptom improvement and 13.4% reported little or no relief. Only 1 study used a comparison group, but patients in it received conservative treatment because they were ineligible for vein embolization therapy, so outcomes after the 2 interventions cannot be compared. Therefore, it is not possible to draw conclusions from these data because of a lack of a placebo control or comparative data from alternative interventions.

Because of the lack of standardized diagnostic criteria for pelvic congestion and published randomized controlled trials using well-defined eligibility criteria, there is inadequate data to permit scientific conclusions regarding the efficacy of this procedure.
References


Ball E, Khan KS, Meads C. Does pelvic venous congestion syndrome exist and can it be treated? Acta Obstet Gynecol Scand. 2012;91(5):525-8.

Barbieri, R. Treatment of chronic pelvic pain in women. 08/24/2017. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed December 20, 2017.

Cordts PR, Eclavea A, Buckley PJ, et al. Pelvic congestion syndrome: early clinical results after transcatheter ovarian vein embolization. J Vasc Surg. 1998;28(5):862-868.

Daniels JP, Champaneria R, Shah L, et al. Effectiveness of embolization or sclerotherapy of pelvic veins for reducing chronic pelvic pain: a systematic review. J Vasc Interv Radiol. 2016;27(10):1478-1486.

Daniels JP, Champaneria R, Shah L, et al. Effectiveness of embolization or sclerotherapy of pelvic veins for reducing chronic pelvic pain: a systematic review. J Vasc Interv Radiol. 2016;27(10):1478-1486.e8.

Dorobisz TA, Garcarek JS, Kurcz J, et al. Diagnosis and treatment of pelvic congestion syndrome: Single-centre experiences. Adv Clin Exp Med. 2017;26(2):269-276.

Gandini R, Chiocchi M, Konda D, et al. Transcatheter foam sclerotherapy of symptomatic female varicocele with sodium- tetradecyl-sulfate foam. Cardiovasc Intervent Radiol. 2008;31(4):778-784.

Ganeshan A, Upponi S, Hon LQ, et al. Chronic pelvic pain due to pelvic congestion syndrome: the role of diagnostic and interventional radiology. Cardiovasc Intervent Radiol. 2007;30(6):1105-1111.

Hocquelet A, Le Bras Y, Balian E, et al. Evaluation of the efficacy of endovascular treatment of pelvic congestion syndrome. Diagn Interv Imaging. 2014;95(3):301-6.

Johnson NR. Vulvovaginal varicosities and pelvic congestion syndrome. 05/08/2017. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed December 20, 2017.

Kies DD, Kim HS. Pelvic congestion syndrome: a review of current diagnostic and minimally invasive treatment modalities. Phlebology. 2012;27(Suppl 1):52-7.

Kim D, Baer SD. Interventional radiology in management of gynecological disorders. 01/15/2016. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed December 20, 2017.

Kim HS, Malhotra AD, Rowe PC, et al. Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol. 2006:17(2 Pt 1):289-297.

Kwon SH, Oh JH, Ko KR, et al. Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome. Cardiovasc Intervent Radiol. 2007;30(4):655-661.

Laborda A, Medrano J, de Blas I, et al. Endovascular Treatment of Pelvic Congestion Syndrome: Visual Analog Scale (VAS) Long-Term Follow-up Clinical Evaluation in 202 Patients. Cardiovasc Intervent Radiol. 2013;36(4):1006-14.

Maleux G, Stockx L, Wilms G, Marchal G. Ovarian vein embolization for the treatment of pelvic congestion syndrome: long-term technical and clinical results. J Vasc Interv Radiol. 2000;11(7):859-864.

Mahmoud O, Vikatmaa P, Aho P, et al. Efficacy of endovascular treatment for pelvic congestion syndrome. J Vasc Surg Venous Lymphat Disord. 2016;4(3):355-370.

Monedero JL, Ezpeleta SZ, Perrin M. Pelvic congestion syndrome can be treated operatively with good long-term results. Phlebology. 2012; 27 Suppl 1:65-73.

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

Nasser F, Cavalcante RN, Affonso BB, et al. Safety, efficacy, and prognostic factors in endovascular treatment of pelvic congestion syndrome. Int J Gynaecol Obstet. 2014; 125(1):65-8.

Pieri S, Agresti P, Morucci M, et al. Percutaneous treatment of pelvic congestion syndrome. Radiol Med. 2003;105:76-82.

Pyra K, WoŸniak S, Drelich-Zbroja A, et al. Evaluation of effectiveness of embolization in pelvic congestion syndrome with the new vascular occlusion device (ArtVentive EOS™): Preliminary Results. Cardiovasc Intervent Radiol. 2016;39(8):1122-7.

Pyra K, WoŸniak S, Roman T, Czuczwar P, Trojanowska A, Jargie≥≥o T, Paszkowski T. Evaluation of effectiveness of endovascular embolisation for the treatment of pelvic congestion syndrome--preliminary study. Ginekol Pol. 2015;86(5):346-51.

Sichlau MJ, Yao JS, Vogelzang RL. Transcatheter embolotherapy for the treatment of pelvic congestion syndrome. Obstet Gynecol. 1994;83(5 Pt 2):892-896.

Siqueira FM, Monsignore LM, Rosa-E-Silva JC, et al. Evaluation of embolization for periuterine varices involving chronic pelvic pain secondary to pelvic congestion syndrome. Clinics (Sao Paulo). 2016;71(12):703-708.

Society of Interventional Radiology (SIR). Pelvic Congestion Syndrome - Chronic Pelvic Pain in Women (Patient information). Available at: http://www.sirweb.org/patients/chronic-pelvic-pain/. Accessed December 20, 2017.

Stones RW. Pelvic vascular congestion-half a century later. Clin Obstet Gynecol. 2003;46(4):831-836.

Tarazov PG, Prozorovskij KV, Ryzhkov VK. Pelvic pain syndrome caused by ovarian varices. Treatment by transcatheter embolization. Acta Radiol. 1997;38(6):1023-1025.

Tropeano G, Di Stasi C, Amoroso S, et al. Ovarian vein incompetence: a potential cause of chronic pelvic pain in women. Eur J Obstet Gynecol Reprod Biol. 2008;139(2):215-221.

Tu FF, Hahn D, Steege JF. Pelvic congestion syndrome-associated pelvic pain: a systematic review of diagnosis and management. Obstet Gynecol Surv. 2010; 65(5):332-40.

Venbrux AC, Chang AH, Kim HS, et al. Pelvic congestion syndrome (pelvic venous incompetence): impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J Vasc Interv Radiol. 2002;13(2 Pt 1):171-178.

Venbrux AC, Lambert DL. 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(4):395-399.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

EXPERIMENTAL/INVESTIGATIONAL

36012, 37241, 75894


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

EXPERIMENTAL/INVESTIGATIONAL

N94.89 Other specified conditions associated with female genital organs and menstrual cycle



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 11.06.07d
04/23/2018This version of the policy will become effective 04/23/2018. The intent of this policy remains unchanged.

Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 04/23/2018
Version Issued Date: 04/23/2018
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.