Anthem Blue Cross Connecticut SURG.00062 Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele Form

This document addresses ovarian and internal iliac vein embolization as a treatment for pelvic congestion syndrome (PCS), and percutaneous testicular vein embolization for varicocele.

PCS, which is also referred to as pelvic venous incompetence (PVI), is a condition involving chronic pelvic pain (CPP) which is non-cyclic and of variable location and intensity. The CPP is usually aggravated by prolonged standing. The underlying etiology is thought to be related to varices of the ovarian veins, leading to pelvic congestion. As there are many etiologies for CPP, PCS is often a diagnosis of exclusion, when varices are identified using a variety of imaging methods, such as magnetic resonance imaging (MRI), computed tomography (CT) scanning or contrast venography. For those who do not respond to medical therapy with analgesics, embolization therapy of the ovarian and internal iliac veins has been proposed.

Testicular varicocele is a condition in which high hydrostatic pressure in the testicular veins (also called the spermatic veins) is thought to cause discomfort, pain and reduced fertility. Percutaneous embolization therapy has been used to treat varicocele as an alternative to surgical ligation (varicocelectomy) to improve symptoms, sperm count and sperm motility.

Position Statement

Investigational and Not Medically Necessary:

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

Embolization of the testicular (spermatic) veins is considered investigational and not medically necessary as a treatment of testicular varicocele.