Clinical UM Guideline
|Guideline #:||CG-MED-48||Current Effective Date:||06/28/2016|
|Status:||Revised||Last Review Date:||05/05/2016|
This document addresses the use of ultrasound imaging technologies for the evaluation of conditions affecting the scrotum and testes.
The use of scrotal ultrasound is considered medically necessary for the following conditions:
Not Medically Necessary:
The use of scrotal ultrasound is considered not medically necessary for the localization of undescended testes.
The use of scrotal ultrasound is considered not medically necessary for any condition not listed above.
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|76870||Ultrasound, scrotum and contents|
|C62.00-C62.92||Malignant neoplasm of testis|
|C63.00-C63.9||Malignant neoplasm of other and unspecified male genital organs|
|C79.82||Secondary malignant neoplasm of genital organs|
|D07.60-D07.69||Carcinoma in situ of other and unspecified male genital organs|
|D29.20-D29.22||Benign neoplasm of testis|
|D29.30-D29.9||Benign neoplasm of epididymis, scrotum, other male genital organs|
|D40.10-D40.12||Neoplasm of uncertain behavior of testis|
|D40.8-D40.9||Neoplasm of uncertain behavior of other and unspecified male genital organs|
|D49.5||Neoplasm of unspecified behavior of other genitourinary organs|
|N43.0-N43.42||Hydrocele and spermatocele|
|N44.00-N44.8||Noninflammatory disorders of testis|
|N45.1-N45.4||Orchitis and epididymitis|
|N50.0-N50.9||Other disorders of male genital organs|
|Q53.00-Q53.9||Undescended and ectopic testicle|
|Q55.0-Q55.4||Other congenital malformations of male genital organs|
|S30.22XA-S30.22XS||Contusion of scrotum and testes|
|S30.843A-S30.843S||External constriction of scrotum and testes|
|S30.853A-S30.853S||Superficial foreign body of scrotum and testes|
|S30.94XA-S30.94XS||Unspecified superficial injury of scrotum and testes|
|S31.30XA-S31.35XS||Open wound of scrotum and testes|
|S38.02XA-S38.02XS||Crushing injury of scrotum and testis|
|S39.848A-S39.848S||Other specified injuries of external genitals|
|S39.94XA-S39.94XS||Unspecified injury of external genitals|
Ultrasonography (US) is a medical technology that uses sound waves to create images of internal structures of the body or to evaluate their function. US is a widely accepted technique in the evaluation of scrotal conditions, allowing for medical evaluation of serious conditions without the need for invasive surgery or techniques that expose individuals to radiation.
The American Institute of Ultrasound Medicine (AUIM) published its Practice Guideline for the Performance of Scrotal Ultrasound Examinations in 2011. This document, which was jointly developed with the American College of Radiology (ACR) and Society of Radiologists in Ultrasound, provides guidance for a wide variety of indications where US is understood to be beneficial, including acute scrotum, which may be caused by a wide variety of conditions. US evaluation for acute scrotum is supported by over 20 years of study data indicating sensitivity between 70-100% and specificity between 88-100% (Al Mufti, 1995; Paltiel, 1998, Vajayaraghavan, 2006; Wilbert, 1993; Yazbeck, 1994). One cause of acute scrotum is testicular torsion. Several studies have investigated the use of US for the evaluation of this condition specifically, indicating sensitivity between 63-86%, specificity between 89-100%, and accuracy between 99-100% (Baker, 2000; Baldisserotto, 2005; Burks, 1990; Kalfa, 2007; Karmazyn, 2005). The most recent data, from a large study conducted by Yagil and colleagues (2010), reported that sensitivity, specificity, and accuracy of US was 94%, 96%, and 99.5% for testicular torsion, 92%, 95%, and 94% for testicular malignancy, and 100%, 98.5%, 98.5% for testicular hematoma, respectively. This study also reported on the beneficial use of US for hydrocele, hernia, testicular mass, abscess, chryptorchidism, and orchiepididymitis.
US can also indicated in the work up of infertility. Pierik and others conducted a large study of 1372 subjects with suspected infertility, in which they reported sensitivity of 65.7% and specificity of 91% (1999).
In 2013, Abdulwahed and others published the findings of a prospective case series study involving 268 azoospermic men who underwent both scrotal and transrectal US evaluation. All subjects had previously undergone biopsy and had histopathological results available. The authors reported that the sensitivity and specificity of scrotal US in detecting nonobstructive azoospermia was 75% and 72%, respectively. For obstructive azoospermia, sensitivity and specificity was reported as 29.8% and 87%, respectively. Rectal US was 45% sensitive and and 83% specific in detecting obstructive azoospermia and 39% sensitive and 88% specific in detecting functional azoospermia. While scrotal US was more sensitive in detecting functional azoospermia and more specific in detecting obstructive azoospermia, transrectal US was more sensitive in detecting obstructive azoospermia and more specific in detecting functional azoospermia. The authors noted that both tests had greater specificity than sensitivity for obstructive azoospermia, indicating that US has the ability to exclude more than to diagnose cases of obstructive azoospermia.
The ACR, in its Appropriateness Criteria for children and adults with acute onset of scrotal pain without trauma or antecedent mass, rates the appropriateness of US for the evaluation of the scrotum a 9 out of 9, indicating "usually appropriate" (2011). They comment that color doppler ultrasound:
Is the study of choice to evaluate patients with acute scrotal pain due to its widespread availability and its ability to diagnose testicular torsion with a high degree of sensitivity and specificity and to distinguish other causes of scrotal pain and swelling.
A meta-analysis published by Tasian and Copp (Tasian, 2011b) found that US for undescended testis has a sensitivity of 45% (95% confidence interval [CI], 29-61) and a specificity of 78% (95% CI, 43-94). The positive and negative likelihood ratios are 1.48 (95% CI, 0.54-4.03) and 0.79 (95% CI, 0.46-1.35), respectively. The authors stated that a positive ultrasound result increases and negative ultrasound result decreases the probability that a nonpalpable testis is located within the abdomen from 55% to 64% and 49%, respectively. They conclude: "Ultrasound does not reliably localize nonpalpable testes and does not rule out an intraabdominal testis. Eliminating the use of ultrasound will not change management of nonpalpable cryptorchidism."
Hydroceles: A condition where there is abnormal fluid buildup within the scrotum around the testicle.
Metastatic germ cell tumors: Cancer cells that are derive from cells involved with the production of sperm or eggs, which have migrated from their point of origin to another location in the body.
Occult primary tumor: A cancer cell that has an unknown point of origin.
Testicular ischemia: A condition where blood supply to the testes is insufficient.
Testicular neoplasm: Cancer of the testes.
Testicular torsion: A condition where the spermatic cord suspending the testicles becomes twisted, interfering with normal blood supply.
Undescended testes: Also known as cryptorchidism. A condition characterized by absence of one or both testes from the scrotum.
Varicoceles: A condition where the complex of veins draining from the structures within the scrotum becomes enlarged.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Revised||05/05/2016||Medical Policy & Technology Assessment Committee (MPTAC) review. Removed the term "male" from MN criteria addressing evaluation for infertility. Updated Rationale and Reference sections. Removed ICD-9 codes from Coding section.|
|Reviewed||05/07/2015||MPTAC review. Updated Rationale and Reference section.|
|Reviewed||05/15/2014||MPTAC review. No change to clinical indications. Updated Reference section.|
|New||05/09/2013||MPTAC review. Initial document development.|