Q53.13 — Unilateral high scrotal testis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must be submitted with the most appropriate and applicable covered diagnosis code(s) listed in the policy; services billed without a covered diagnosis code will be denied.
- Clinical documentation must support one of the listed medically necessary indications (e.g., documentation of acute scrotal pain, trauma, suspected torsion, mass, infertility evaluation, family history of testicular cancer, varicocele, hydrocele, nonpalpable testes age ≥6 months, suspected occult inguinal hernia).
- A thorough history and physical examination is expected; physical exam documentation should include findings in both standing and supine positions where relevant.
- For suspected inguinal (occult) hernia, documentation should indicate inability to confirm diagnosis on physical exam (including standing and Valsalva maneuver) prior to ordering scrotal ultrasound.
Key Coverage Criteria
- Acute scrotal pain or testicular torsion
- Acute scrotal trauma or injury
- Suspected infectious or inflammatory scrotal disease (e.g., epididymitis, orchitis, epididymo-orchitis, abscess of epididymis or testis)
- Scrotal neoplasm or mass (including suspected intratesticular mass)
- Family history of testicular cancer / germ cell tumor (GCT)
- Scrotal varices (varicocele)
2 Active Policies
CIGNA-0548 — Scrotal Ultrasound - (0548)
ANTHEM-CG-LAB-27 — CG-LAB-27 Human Chorionic Gonadotropin Testing
Related Codes
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