Therapeutic Embolization and Vessel Occlusion to Treat Pelvic Conditions

This policy covers transcatheter therapeutic embolization and vessel occlusion for pelvic conditions — including uterine artery embolization (UAE) for fibroids causing profuse bleeding, anemia, pain/pressure, or palpable concern; embolization for postpartum hemorrhage; ovarian/internal iliac vein embolization for pelvic congestion syndrome (PCS); testicular (gonadal) vein embolization for symptomatic varicocele; and embolization for uterine AVM, cervical ectopic pregnancy, adenomyosis, and selected chronic pelvic pain (CPP) cases. Coverage for CPP requires symptoms ≥6 months that interfere with activities of daily living, failure of ≥6 months of pharmacotherapy, OB/GYN evaluation, and appropriate diagnostic imaging, and PCS embolization is covered only when all specified clinical and imaging criteria are documented. Major limitations: only one repeat UAE is allowed and only with imaging evidence of incomplete prior embolization; procedures or indications not meeting policy criteria are considered investigational, device use must be FDA‑cleared for the intended use, and evidence is limited for women desiring future pregnancy.