Scrotal Ultrasonography
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This policy defines when scrotal ultrasonography is considered medically necessary or experimental for Aetna members, including indications such as scrotal masses, acute scrotal symptoms, infertility evaluation, trauma, and undescended testes.
No material clinical or coverage changes in this revision.
Coverage Criteria for Scrotal Ultrasonography
inv-01: Medically necessary — Aetna considers scrotal ultrasonography medically necessary for any of the following:
Aetna considers scrotal ultrasonography medically necessary for any of the following:
Preserves policy OR logic as listed.
inv-02: Experimental, investigational, or unproven — Scrotal ultrasonography is considered experimental, investigational, or unproven for all other indications, including (but not limited to):
Scrotal ultrasonography is considered experimental, investigational, or unproven for all other indications, including (but not limited to):
Policy lists these examples as unproven uses.
inv-03: Scrotal/Transrectal Ultrasound Indications (Initial infertility evaluation and scrotal pathology)
Covered when clinical indications or examination findings warrant imaging:
Reflects AUA/ASRM, French guidelines and UpToDate summaries.
inv-04: Testicular torsion imaging guidance — Ultrasound findings relevant to torsion:
Ultrasound findings relevant to torsion:
Meta-analysis (McDowall et al.) results.
inv-05: Testicular microlithiasis follow-up — Coverage/management stance for TML:
Coverage/management stance for TML:
ESUR scrotal imaging subcommittee guidance.
Aetna excludes routine ultrasound surveillance for testicular microlithiasis (TML) when no additional risk factors are present. The policy specifies that surveillance is not advised for isolated TML in the absence of risk factors such as a history of cryptorchidism, prior testicular cancer, or testicular atrophy (testis volume <12 mL).
If additional risk factors are present, the policy references consideration of periodic imaging (for example, annual ultrasound up to age 55 per guideline guidance), and an urgent specialist referral is recommended when TML is identified in conjunction with a testicular mass.
Aetna discourages routine scrotal ultrasound as part of the initial infertility evaluation. Scrotal ultrasonography is not routinely indicated for all men presenting for initial fertility assessment and should be ordered only when the clinical examination cannot be adequately performed (for example, obese patients or contracted dartos muscle) or when a testicular mass is suspected.
Claims submitted for CPT 76870 associated with encounter codes for initial fertility testing (e.g., Z31.41, Z31.49) may be subject to denial if the selection criteria in the policy are not met; ensure documentation supports a covered indication before ordering and billing.
This Clinical Policy Bulletin provides Aetna’s guidance to assist in administering plan benefits and is not a contract or an offer of coverage. It contains a general description of plan or program benefits, may be updated, and does not replace the provider’s clinical judgment or plan-specific benefit documents. Providers remain solely responsible for medical advice and treatment of members.
Scrotal ultrasonography for the initial evaluation of infertility is not medically necessary unless one of the following applies: the physical examination of the scrotum is difficult or inadequate (for example, obesity or contracted dartos muscle) or a testicular mass is suspected. When these criteria are not met, the policy lists initial infertility encounter codes (e.g., Z31.41, Z31.49) as not covered.
When ordering ultrasound for infertility indications that meet the policy, document the specific exam limitations or mass suspicion and relevant semen analysis or physical findings to support medical necessity.
Ultrasound evaluation for undescended testis (UDT) has limited diagnostic value and is frequently overused. The policy cites studies showing modest accuracy and potential delays in definitive surgical management when ultrasound is performed routinely.
Routine preoperative ultrasound for UDT is generally discouraged and may be considered unnecessary when ordering without clear, guideline-supported indications; providers should rely primarily on clinical examination and surgical findings when planning management unless specific circumstances (e.g., non-palpable testes, obesity) justify imaging.
Coding and Codes
| 76870 | Ultrasound, scrotum and contents. |
| C63.2 | Malignant neoplasm of scrotum. |
| D29.4 | Benign neoplasm of scrotum. |
| D40.10 | Neoplasm of uncertain behavior of testis. |
| D40.11 | Neoplasm of uncertain behavior of testis. |
| D40.12 | Neoplasm of uncertain behavior of testis. |
| I86.1 | Scrotal varices. |
| N43.0 | Hydrocele and spermatocele. |
| N43.1 | Hydrocele and spermatocele. |
| N43.2 | Hydrocele and spermatocele. |
| N43.3 | Hydrocele and spermatocele. |
| Z31.41 | Encounter for fertility testing [Initial evaluation for infertility unless physical examination of the scrotum is difficult or inadequate, or when a testicular mass is suspected]. |
| Z31.49 | Encounter for other procreative investigation and testing [Initial evaluation for infertility unless physical examination of the scrotum is difficult or inadequate, or when a testicular mass is suspected]. |
| No codes listed |
Provider Actions, Documentation, and Billing Notes
Use CPT 76870 only when selection criteria are met
CPT 76870 (Ultrasound, scrotum and contents) is a covered procedure when the policy’s selection criteria are met; providers should verify that the clinical indication maps to a covered ICD‑10 code prior to billing.
- Covered CPT code: 76870 — Ultrasound, scrotum and contents.
- Ensure the documented clinical indication corresponds to one of the policy’s medically necessary indications before submission.
Order scrotal US only for indicated infertility scenarios
Do not order scrotal ultrasound routinely for the initial infertility evaluation. Reserve imaging when the scrotal physical examination is difficult or inadequate (e.g., obesity, contracted dartos) or when a testicular mass is suspected; TRUS is indicated only for patients with semen analysis findings suggestive of ejaculatory duct obstruction.
- Scrotal US is discouraged as part of routine initial infertility workup.
- Use color Doppler US when the exam is limited (obesity, contracted dartos) or when a mass is suspected.
- TRUS should be reserved for men with semen analysis findings consistent with ejaculatory duct obstruction.
No special prior‑authorization process specified
The policy does not specify a separate prior authorization program or unique prior authorization steps for scrotal ultrasonography; follow standard plan administrative procedures and verify coverage using the selection criteria in this policy.
- No explicit prior‑authorization workflow for scrotal ultrasound is detailed in this Clinical Policy Bulletin.
- Confirm coverage by ensuring the exam meets the medically necessary indications listed in the policy.
Provider action
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No step therapy required
No step therapy requirements are specified for scrotal or transrectal ultrasonography in this policy.
- The policy lists no prerequisites, staged treatments, or step edits prior to ordering ultrasound.
Provider action
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Document the clinical indication that supports medical necessity
Document the specific clinical indication and that it matches one of the policy’s medically necessary reasons (e.g., scrotal mass, suspected torsion, hydrocele, infertility when the scrotal exam is difficult/inadequate, trauma, varicocele, undescended testis).
- Record the clinical scenario that justifies imaging and reference the corresponding medically necessary criterion from the policy.
- Ensure the indication maps to a covered ICD‑10 code when submitting the claim.
Include exam findings and semen analysis to support the indication
Include relevant physical exam findings and diagnostic test results to support medical necessity when ordering or billing for scrotal or transrectal ultrasound (e.g., difficult/inadequate scrotal exam due to obesity or contracted dartos, non‑palpable or suspicious mass, semen analysis results suggesting obstructive azoospermia).
- Document specific exam limitations (obesity, contracted dartos) or palpation findings (non‑palpable testis, palpable mass).
- For infertility/TRUS indications, include semen analysis details (azoospermia, low semen volume <1.5 mL, acidic semen) if applicable.
Provider responsibilities and policy status
Providers are independent contractors and are solely responsible for medical advice and treatment; this Clinical Policy Bulletin is a partial description of plan benefits, may be updated, and does not constitute a contract or medical advice.
- This bulletin assists in administering plan benefits but is not an offer of coverage.
- Treating providers retain responsibility for clinical decisions and member care.
Denial risk when using infertility encounter codes without supporting exam findings
Claims filed with ICD‑10 codes Z31.41 or Z31.49 (encounters for fertility testing/procreative investigation) are listed as not covered when used for routine initial infertility evaluation unless the scrotal exam is difficult/inadequate or a testicular mass is suspected; such submissions risk denial if selection criteria are not met.
- Z31.41 and Z31.49 are specifically noted as not covered for initial infertility evaluation when selection criteria are not satisfied.
- Ensure documentation demonstrates exam inadequacy or a suspected mass to avoid denial.
Avoid routine scrotal US for initial infertility evaluation
Routine ordering of scrotal ultrasound for the initial infertility evaluation is discouraged and may be considered inappropriate use; order imaging only when the physical exam is difficult/inadequate or a testicular mass is suspected to avoid unnecessary utilization.
- Routine screening in initial infertility without exam limitations or mass suspicion is discouraged.
- Ordering without appropriate indication may lead to challenge or denial.
Risk of inappropriate ultrasound use for undescended testis (UDT)
Ultrasound is of limited value for undescended testis (UDT) and has been widely overused; ordering preoperative or routine US for UDT without a clear indication may delay care, increase costs, and be challenged.
- Studies show ultrasound correctly predicted surgical findings in only ~54% of patients and was associated with delays in definitive management.
- Avoid routine preoperative ultrasound for UDT unless specifically justified.
Policy bulletin is guidance, not a contract
Clinical Policy Bulletins are developed to assist in administering plan benefits and do not constitute a contract or medical advice; they may be updated and participating providers remain responsible for member care.
- The bulletin is a general description of plan benefits and is subject to change.
- Providers are independent contractors and responsible for treatment decisions.
Background and Rationale
Scrotal ultrasonography is a sensitive modality for identifying intra-scrotal abnormalities and distinguishing testicular from para-testicular lesions. Color Doppler ultrasound is particularly valuable for assessing scrotal blood flow in acute scrotal conditions, such as suspected testicular torsion, and for evaluating testicular perfusion after trauma.
Ultrasound is also useful for evaluation of hydroceles, varicoceles (defined in the policy as intra-scrotal veins larger than 2 mm), undescended testes in selected circumstances, and as part of infertility workup when the physical examination is inadequate or a mass is suspected.
Definitions
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