37241
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
8.53
Facility
$371.08
Non-Facility
$4393.22
Documentation Required
- Definitive diagnostic venography, computed tomography (CT) or magnetic resonance imaging (MRI) documenting pelvic venous pathology (explicitly required by the policy).
- Documentation of a failed trial of appropriate pharmacotherapy (e.g., analgesics, hormonal therapy) prior to consideration of embolization (explicitly required by the policy).
- Appropriate ICD-10 diagnosis coding supporting PCS: N94.89 (Other specified conditions associated with female genital organs and menstrual cycle [pelvic congestion syndrome]) when selection criteria are met.
- Medical records supporting the clinical diagnosis of PCS (e.g., chronic pelvic pain consistent with PCS, prior conservative/medical therapy) to substantiate that the member meets the policy's 'both criteria' for medical necessity.
Key Coverage Criteria
- Embolization (e.g., using metallic coils or foam/gel sclerotherapy) of gonadal veins or ovarian veins, with or without the internal iliac veins, medically necessary for the treatment of pelvic congestion syndrome (PCS) when both of the following criteria are met: The member has had a definitive diagnostic venography, computed tomography (CT) or magnetic resonance imaging (MRI); and The member has failed a trial of appropriate pharmacotherapy (e.g., analgesics, hormonal therapy).
- Gonadal vein or ovarian vein embolization (including gonadal vein embolization) for pelvic congestion syndrome when the above selection/medical necessity criteria are met (ICD-10: N94.89).
- Trans-venous occlusion / vascular embolization or occlusion (CPT 37241) using metallic coils or foam/gel sclerotherapy for pelvic congestion syndrome when selection/medical necessity criteria are met (ICD-10: N94.89).
- Covered CPT/HCPCS procedure codes for embolization when selection criteria are met: examples listed include 36245, 36246, 36247, 36248 (selective catheter placement codes), 37241 (vascular embolization/occlusion, venous, including gonadal vein embolization), 75894 (transcatheter therapy, embolization), and 75898 (angiography through existing catheter for follow-up).
- ICD-10 diagnosis listed as covered when selection criteria are met: N94.89 (Other specified conditions associated with female genital organs and menstrual cycle [pelvic congestion syndrome]).
- ICD-10 codes covered if selection criteria are met: E29.1 (Testicular hypofunction); I86.1 (Scrotal varices); N46.023 (Azoospermia due to obstruction of efferent ducts); N46.11 - N46.129 (Oligospermia)
16 Active Policies
AETNA-CPB-0413 — Varicocele: Selected Treatments
CARELON-vascular-embolization-occlusion-2024-11-01 — Vascular Embolization Occlusion
UMR-POL-UMR-embolization-ovarian-iliac-veins-pelvic-congestion-syndrome-umr — Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome – UMR Medical Policy
AETNA-CPB-0050 — Varicose Veins
Related Codes
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