Q53.9 — Undescended testicle, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The patient's medical record must document medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
- A claim submitted without a valid ICD‑10‑CM diagnosis code that best describes the condition will be returned as an incomplete claim under §1833(e) of the Social Security Act.
- For diagnostic tests, report the test result if known on the claim; if result is not known, report the symptoms that prompted the test.
Key Coverage Criteria
- Medicare may cover injectable testosterone pellets (Testopel) for males when used for an FDA‑approved indication and when the service meets Medicare coverage requirements in CMS Medicare Benefit Policy Manual, Chapter 15, §50.4.3.
- Injectable testosterone pellet therapy may be used when alternative accepted routes (transdermal, oral, nasal, intramuscular) are clinically inappropriate or insufficient and medical necessity is documented.
- Testosterone therapy is covered for symptomatic hypogonadism (congenital or acquired) due to a disorder of the testicles, pituitary gland, or brain.
- Testosterone therapy is covered for delayed male puberty.
- Testosterone therapy is covered for gender dysphoria in a member who is able to make an informed decision to engage in hormone therapy.
- Primary hypogonadism may be established when at least two separate fasting serum testosterone levels, drawn prior to 10:00 AM on two different days from identical laboratories, are low and a single LH or FSH level is elevated.
8 Active Policies
CIGNA-0548 — Scrotal Ultrasound - (0548)
AETNA-CPB-0327 — Infertility
AETNA-CPB-0532 — Scrotal Ultrasonography
UHC-POL-testosterone-replacement-supp-therapy — Testosterone Replacement or Supplementation Therapy
ANTHEM-CG-RAD-27 — CG-RAD-27 Scrotal Ultrasound
Related Codes
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