55540
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
8.09
Facility
$540.09
Non-Facility
$540.09
Documentation Required
- Documentation of varicocele grade (physical exam findings) — e.g., grade 2 (palpable without Valsalva) or grade 3 (visible)
- For adolescents: documentation of ipsilateral testicular growth retardation (testicular size measurements or growth charts) when treating grade 2 or 3 varicoceles
- For infertility indications: pre-procedure semen analysis demonstrating decreased sperm motility and reduced sperm concentration (results and dates)
- For recurrent varicocele: prior surgical/ligation operative report(s) and documentation of recurrence
Key Coverage Criteria
- 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)
- Percutaneous embolization (by balloon or metallic coil) or ligation is medically necessary for treatment of varicocele for adolescents with grade 2 or 3 varicoceles associated with ipsilateral testicular growth retardation.
- Percutaneous embolization (by balloon or metallic coil) or ligation is medically necessary for treatment of varicocele for males with infertility problems who have decreased sperm motility and lower sperm concentrations.
- Percutaneous embolization (by balloon or metallic coil) or ligation is medically necessary for treatment of post-surgical (ligation) recurrence of varicoceles.
- Percutaneous embolization (by balloon or metallic coil) or ligation is medically necessary for treatment of scrotal pain associated with varicoceles.
- Microsurgical varicocelectomy is an acceptable alternative method of treating a varicocele when any of the above criteria are met.
1 Active Policy
AETNA-CPB-0413 — Varicocele: Selected Treatments
Related Codes
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