Pelvic congestion syndrome (PCS) is a condition of chronic pelvic pain (CPP) of variable location and intensity, which is aggravated by standing. The underlying etiology is thought to be related to varices of the ovarian veins, leading to pelvic congestion. As there are many etiologies of CPP, PCS is often a diagnosis of exclusion, with the identification of varices using a variety of imaging methods, such as MRI, CT scanning or contrast venography. For those who fail medical therapy with analgesics, surgical ligation of the ovarian vein has been considered. More recently, embolization therapy of the ovarian and internal iliac veins has been proposed. This policy addresses ovarian and internal iliac vein embolization as a treatment of PCS.

Investigational/Not Medically Necessary:

Embolization of the ovarian vein and internal iliac veins is considered investigational/not medically necessary as a treatment of pelvic congestion syndrome.

Rationale

The literature regarding the clinical outcomes of embolization therapy is relatively sparse, consisting of a number of case series and one randomized comparative trial. Several small case series report pain relief in from 50-80% of patients (Sichlau, 1994; Tarazov, 1997, Cordis, 1998).  In a case series (n=56), Venbrux and colleagues (2002) performed bilateral ovarian vein embolization therapy, followed 3 to 10 weeks later by embolization of the internal iliac veins. The procedures were considered a technical success in all patients, although in two patients the coils inadvertently embolized to the pulmonary circulation where they were retrieved without incident.  Recurrences of varices were noted in three patients.  In terms of pain control, the mean VAS score fell from 7.8 to 2.7 over a 12 month period.  In a case series of 41 patients who underwent ovarian vein embolization, Maleux and colleagues (2000) reported a technical success rate of 98%.  68.3% of patients reported either partial or complete pain relief. However, there was no formal assessment of pain prior to the procedure. Chung (2003) compared the efficacy of embolization (n=52) to that of hysterectomy and bilateral oophorectomy (n=27) or hysterectomy and unilateral oophorectomy (n=27). Furthermore, patients were stratified according to stress scores into three subgroups with normal, moderate-high and very high stress levels. A significant improvement in pain symptoms was observed in the three treatment groups. Patients with normal to moderate-high stress levels who received embolization experienced superior symptom relief compared to patients who underwent hysterectomy with unilateral or bilateral oophorectomy. However, patients with very high stress levels did not derive as much treatment benefit as patients with normal to moderate-high stress levels.

The published data regarding embolization therapy for pelvic congestion syndrome are inadequate to permit scientific conclusions, due to small sample sizes, lack of control groups, lack standardized diagnostic criteria, and the predominant use of patient self-assessed, subjective outcome measures. Additional data from larger randomized control studies are required to establish safety and efficacy of this procedure.  As such, ovarian and internal iliac vein embolization as a treatment of PCS is considered investigational/not medically necessary.

Background/Overview

Description of Disease

Pelvic congestion syndrome is a condition of chronic pelvic pain of variable location and intensity, which is aggravated by standing. The syndrome is also often associated with dyspareunia and postcoital pain and typically affects young multiparous women. The underlying etiology is thought to be related to varices of the ovarian veins, leading to pelvic congestion. Approximately 10-15% of women may have pelvic varicose veins but not all will have symptoms. As there are many etiologies of chronic pelvic pain, the pelvic congestion syndrome is often a diagnosis of exclusion. The presence of pelvic varices associated with the syndrome, however, may be identified using a variety of imaging methods, such as MRI, CT scanning or contrast venography.

Description of Technology

For those who fail medical therapy (e.g., analgesics, vasoconstrictors and hormonal therapies), surgical ligation of the ovarian vein may be considered. More recently, catheter-based embolization therapy of the ovarian and internal iliac veins has been proposed. Catheter-based therapies may be performed on an inpatient or outpatient basis depending on the veins that are accessed and the technique that is used. Ovarian and internal iliac vein embolization is a therapy used to block blood flow to the veins causing pelvic congestion. It is performed by accessing the venous system by a catheter and injecting an inert material to clog the affected veins. The embolization procedure may require multiple sessions. For example, one method involves use of gel foam and coils for embolization of the ovarian vein(s). This may be followed 3 to 10 weeks later by embolization of the internal iliac veins to reduce the risk of recurrence.

Proposed Benefits

Ovarian and internal iliac vein embolization is proposed as an alternative to major surgery for patients who are refractory to medical treatment. This procedure is suggested as a way to reduce pain from pelvic congestion syndrome.

Possible Risks

Occasionally the coils may embolize to another area of the body such as the pulmonary circulation, necessitating a retrieval procedure. In some patients, the ovarian varices may return and thus a re-performance of the procedure is needed. 

Definitions

Embolization: a procedure in which targeted blood vessels are obstructed by delivering material into the circulatory system

Pelvic congestion syndrome: a syndrome of chronic pelvic pain that is generally associated with enlarged veins(varices) in the pelvic area (e.g., ovarian veins)

Coding

The following codes for treatments and procedures applicable to this policy are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational/Not Medically Necessary:

CPT

ICD-9 Diagnosis

References

Peer Reviewed Publications:

1. Bachar GN, Belenky A, Greif F, et al. Initial experience with ovarian vein embolization for the treatment of chronic pelvic pain syndrome. Isr Med Assoc J. 2003; 5(12):843-6.
2. Chung MH, Huh CY.  Comparison of treatments for pelvic congestion syndrome. Tohoku J Exp Med. 2003; 201(3):131-138.
3. Cordis PR, Eclavea A, Buckley PJ et al.  Pelvic congestion syndrome: Early clinical results after transcatheter ovarian vein embolization.  J Vasc Surg 1998; 28:862-868. 
4. Hobbs JT. Varicose veins arising from the pelvis due to ovarian vein incompetence. Int J Clin Pract. 2005; 59(10):1195-203.
5. 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.
6. 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 Interven Radiol 2000;11:859-864. 
7. Pieri S, Agresti P, Morucci M, de' Medici L. Percutaneous treatment of pelvic congestion syndrome. Radiol Med (Torino). 2003; 105(1-2):76-82.
8. Sichlau MU, Yao JST, Vogelzang L.  Transcatheter embolotherapy for the treatment of pelvic congestion syndrome.  Obstet Gynecol 1994; 83:892-896. 
9. Stones RW.  Pelvic vascular congestion - Half a century later.  Clin Obstet Gynecol 2003;46:831-36. 
10. Tarazov PB, Prozorovakji KV, Ryzhov VK.  Pelvic pain syndrome caused by ovarian varices: treatment of transcatheter embolization.  Acta Radiol 1997; 98:1023-1025. 
11. 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 Vas Inter Radiol 2002; 13:171-178. 
12. 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; 11:395-399.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Centers for Medicare and Medicaid Services. National Coverage Determination for Therapeutic Embolization. NCD #20.28. Effective December 15, 1978. Available at:  http://www.cms.hhs.gov/mcd/index_chapter_list.asp .  Accessed on: March 21, 2007.
2. Hayes, Inc. Hayes Technology Brief Assessment. Coil Embolization of the Ovarian Vein for Pelvic Congestion Syndrome. Lansdale, PA: Hayes, Inc.; October 2004. 
3. Stones RW, Mountfield J. Interventions for treating chronic pelvic pain in women (Cochrane Review). In: The Cochrane Library , Issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd.

Web Sites for Additional Information

1. Society of Interventional Radiology: Medical Breakthroughs: High-tech “Surgery”: Available at:  http://www.sirweb.org/patPub/Iradiology.shtml. Accessed on March 21, 2007.

Index

Embolization Therapy for Pelvic Congestion Syndrome
Internal Iliac and Ovarian Vein Embolization as a Treatment of Pelvic Congestion Syndrome
Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
Pelvic Congestion Syndrome
Pelvic Pain – Embolization Therapy for Pelvic Congestion Syndrome
Vein Embolization as a Treatment of Pelvic Congestion Syndrome

Policy History

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

©CPT Only - American Medical Association