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Clinical Policy Bulletin:
Scrotal Ultrasonography
Number: 0532


Policy

Aetna considers scrotal ultrasonography medically necessary for any of the following conditions:

  • Detection and characterization of scrotal mass lesions/tumors; or
  • Detection of undescended (cryptorchid) testes; or
  • Diagnosis of suspected testicular torsion; or
  • Evaluation of hydroceles; or
  • Evaluation of infertile men; or
  • Evaluation of scrotal pain and/or swelling (acute scrotal symptoms); or
  • Evaluation of scrotal trauma; or
  • Evaluation of varicoceles.

Aetna considers scrotal ultrasonography experimental and investigational for all other indications because of insufficient evidence of its clinical value for other indications.



Background

Scrotal ultrasonography has been demonstrated to have a clinically significant impact on urologists’ diagnoses of scrotal abnormalities and disorders. Scrotal ultrasound is characterized by high sensitivity in the detection of intra-scrotal abnormalities and is a very good mode for differentiating testicular from para-testicular lesions.  The main indication for color Doppler ultrasound (which can reveal scrotal blood flow) is assessment of acute scrotal symptoms (pain or swelling), especially in the diagnosis of suspected testicular torsion.  The vast majority of boys who exhibit acute scrotal symptoms have non-surgical conditions, usually epididymitis or torsion of the appendix testis.  Since the clinical appearances of these conditions are often similar to that of testicular torsion, imaging is frequently performed to help with diagnosis.  In fact, color Doppler ultrasound is the method of choice for imaging scrotal organs, and allows more objective and precise assessment of varicoceles.  Varicoceles can be diagnosed by showing intra-scrotal veins larger than 2 mm.  It has also been shown that color Doppler ultrasound is more accurate and reliable than physical examination in conjunction with gray-scale ultrasound (which is non-specific and can’t be used to diagnose testicular torsion) in the differential diagnosis of acute scrotum.

Patients with hydroceles large enough to prevent adequate palpation of the testes should undergo scrotal ultrasound.  Sonographic identification of calculi in the hydroceles may prevent further imaging and unnecessary surgery.  Color Doppler ultrasound is also used in the evaluation of traumatized scrotum.  Testis rupture must be diagnosed rapidly and color Doppler ultrasound can be used to evaluate perfusion of the testis.  The prediction of testicular viability following trauma is essential for proper treatment.  Other indications for scrotal ultrasonography are detection of undescended (cryptorchid) testes, and evaluation of infertile men.  It should be noted that intra-abdominal testes can not be located with ultrasound.  Routine scrotal ultrasound has been reported to provide valuable information in the diagnostic evaluation of infertile men and substantially more pathological conditions are detected compared to clinical palpation.  The high prevalence of testicular malignancies underscores the importance of routine scrotal ultrasonography in infertile men.
 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
76870
ICD-9 codes covered if selection criteria are met:
187.7 Malignant neoplasm of scrotum
222.4 Benign neoplasm of scrotum
236.4 Neoplasm of uncertain behavior of testis
456.4 Scrotal varices
603.0 - 603.9 Hydrocele
604.0 - 604.99 Orchitis and epididymitis
606.0 - 606.9 Infertility, male
608.1 Spermatocele
608.20 - 608.24 Torsion of testis
608.3 Atrophy of testis
752.51 Undescended testis
752.52 Retractile testis
752.81 Scrotal transposition
778.6 Congenital hydrocele
959.14 Other injury of external genitals


The above policy is based on the following references:
  1. Older RA, Omary RA, Watson LR. The impact of sonography on the diagnosis of scrotal disorders. J Urol. 1997;158(2):479-480.
  2. Dewbury K. Scrotal ultrasound. Br J Hosp Med. 1997;57(1-2):10-14.
  3. Hamm B. Differential diagnosis of scrotal masses by ultrasound. Eur Radiol. 1997;7(5):668-679.
  4. Horstman WG. Scrotal imaging. Urol Clin North Am. 1997;24(3):653-671.
  5. Namjoshi SP. Calculi in hydroceles: Sonographic diagnosis and significance. J Clin Ultrasound. 1997;25(8):437-441.
  6. Suzer O, Ozcan H, Kupeli S, Gheiler EL. Color Doppler imaging in the diagnosis of the acute scrotum. Eur Urol. 1997;32(4):457-461.
  7. Dubinsky TJ, Chen P, Maklad N. Color-flow and power Doppler imaging of the testes. World J Urol. 1998;16(1):35-40.
  8. Geraghty MJ, Lee FT Jr, Bernsten SA, et al. Sonography of testicular tumors and tumor-like conditions: A radiologic-pathologic correlation. Crit Rev Diagn Imaging. 1998;39(1):1-63.
  9. Pierik FH, Dohle GR, van Muiswinkel JM, et al. Is routine scrotal ultrasound advantageous in infertile men? J Urol. 1999;162(5):1618-1620.
  10. Zahalsky M, Nagler HM. Ultrasound and infertility: Diagnostic and therapeutic uses. Curr Urol Rep. 2001;2(6):437-442.
  11. Pavlica P, Barozzi L. Imaging of the acute scrotum. Eur Radiol. 2001;11(2):220-228.
  12. Bushby LH, Miller FN, Rosairo S, et al. Scrotal calcification: Ultrasound appearances, distribution and aetiology. Br J Radiol. 2002;75(891):283-288.
  13. Dogra VS, Gottlieb RH, Oka M, et al. Sonography of the scrotum. Radiology. 2003;227(1):18-36.
  14. Tasu JP, Faye N, Eschwege P, et al. Imaging of burned-out testis tumor: Five new cases and review of the literature. J Ultrasound Med. 2003;22(5):515-521.
  15. American College of Radiology (ACR), Expert Panel on Urologic Imaging. Acute onset of scrotal pain (without trauma, without antecedent mass). ACR Appropriateness Criteria. Reston, VA: American College of Radiology (ACR); 2001.
  16. Akin EA, Khati NJ, Hill MC. Ultrasound of the scrotum. Ultrasound Q. 2004;20(4):181-200.
  17. Bhatt S, Rubens DJ, Dogra VS. Sonography of benign intrascrotal lesions. Ultrasound Q. 2006;22(2):121-136.
  18. Deurdulian C, Mittelstaedt CA, Chong WK, Fielding JR. US of acute scrotal trauma: Optimal technique, imaging findings, and management. Radiographics. 2007;27(2):357-369.
  19. Dagash H, Mackinnon EA. Testicular microlithiasis: What does it mean clinically? BJU Int. 2007;99(1):157-160.
  20. Lee JC, Bhatt S, Dogra VS. Imaging of the epididymis. Ultrasound Q. 2008;24(1):3-16.
  21. Huyghe E, Izard V, Rigot JM; les membres du Comité d'andrologie de l'association française d'urologie (CCAFU). Optimal evaluation of the infertile male. 2007 French urological association guidelines. Prog Urol. 2008;18(2):95-101.
  22. Bhatt S, Dogra VS. Role of US in testicular and scrotal trauma. Radiographics. 2008;28(6):1617-1629.
  23. Guichard G, El Ammari J, Del Coro C, et al. Accuracy of ultrasonography in diagnosis of testicular rupture after blunt scrotal trauma. Urology. 2008;71(1):52-56.
  24. Mihmanli I, Kantarci F. Sonography of scrotal abnormalities in adults: An update. Diagn Interv Radiol. 2009;15(1):64-73.
  25. Carkaci S, Ozkan E, Lane D, Yang WT. Scrotal sonography revisited. J Clin Ultrasound. 2010;38(1):21-37.
  26. Walker AR, Kogan BA. Cost-benefit analysis of scrotal ultrasound in treatment of adolescents with varicocele. J Urol. 2010;183(5):2008-2011.
  27. American College of Radiology (ACR), American Institute of Ultrasound in Medicine (AIUM), Society of Radiologists in Ultrasound (SRU). ACR-AIUM-SRU practice guideline for the performance of scrotal ultrasound examinations [online publication]. Reston, VA: American College of Radiology (ACR); 2010.
  28. American Institute of Ultrasound in Medicine; American College of Radiology; Society of Radiologists in Ultrasound. AIUM practice guideline for the performance of scrotal ultrasound examinations. J Ultrasound Med. 2011;30(1):151-155.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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