Clinical UM Guideline



Subject: Scrotal Ultrasound
Guideline #:  CG-MED-48 Current Effective Date:    06/28/2017
Status: Reviewed Last Review Date:    05/04/2017

Description

This document addresses the use of ultrasound imaging technologies for the evaluation of conditions affecting the scrotum and testes.

Clinical Indications

Medically Necessary:

The use of scrotal ultrasound is considered medically necessary for the following conditions:

  1. Evaluation of acute scrotal symptoms (for example, pain, swelling) and trauma; or
  2. Evaluation of scrotal asymmetry or enlargement (including suspected hydroceles); or
  3. Evaluation of scrotal masses; or
  4. Detection or evaluation of varicoceles; or
  5. Evaluation of infertility; or
  6. Evaluation of testicular ischemia or torsion; or
  7. Evaluation of suspected infectious or inflammatory scrotal disease; or
  8. Detection of occult primary tumors in individuals with metastatic germ cell tumors.

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.

Coding

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.

CPT  
76870 Ultrasound, scrotum and contents
   
ICD-10 Diagnosis  
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
I86.1 Scrotal varices
N43.0-N43.42 Hydrocele and spermatocele
N44.00-N44.8 Noninflammatory disorders of testis
N45.1-N45.4 Orchitis and epididymitis
N46.01-N46.9 Male infertility
N50.0-N50.9 Other disorders of male genital organs
P83.5 Congenital hydrocele
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
   
Discussion/General Information

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 2015. 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 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.

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."

Definitions

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.

References

Peer Reviewed Publications:

  1. Abdulwahed SR, Mohamed EE, Taha EA, et al. Sensitivity and specificity of ultrasonography in predicting etiology of azoospermia. Urology. 2013; 81(5):967-971.
  2. al Mufti RA, Ogedegbe AK, Lafferty K. The use of Doppler ultrasound in the clinical management of acute testicular pain. Br J Urol. 1995; 76(5):625-627.
  3. Baker LA, Sigman D, Mathews RI, et al. An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion. Pediatrics. 2000; 105(3 Pt 1):604-607.
  4. Baldisserotto M, de Souza JC, Pertence AP, Dora MD. Color Doppler sonography of normal and torsed testicular appendages in children. AJR Am J Roentgenol. 2005; 184(4):1287-1292.
  5. Burks DD, Markey BJ, Burkhard TK, et al. Suspected testicular torsion and ischemia: evaluation with color Doppler sonography. Radiology. 1990; 175(3):815-821.
  6. Cain MP, Garra B, Gibbons MD. Scrotal-inguinal ultrasonography: a technique for identifying the nonpalpable inguinal testis without laparoscopy. J Urol. 1996; 156(2 Pt 2):791-794.
  7. Kalfa N, Veyrac C, Lopez M, et al. Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum. J Urol. 2007; 177(1):297-301.
  8. Karmazyn B, Steinberg R, Kornreich L, et al. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys. Pediatr Radiol. 2005; 35(3):302-310.
  9. Paltiel HJ, Connolly LP, Atala A, et al. Acute scrotal symptoms in boys with an indeterminate clinical presentation: comparison of color Doppler sonography and scintigraphy. Radiology. 1998; 207(1):223-231.
  10. Pierik FH, Dohle GR, van Muiswinkel JM, et al. Is routine scrotal ultrasound advantageous in infertile men? J Urol. 1999; 162(5):1618-1620.
  11. Tasian GE, Copp HL. Diagnostic performance of ultrasound in nonpalpable cryptorchidism: a systematic review and meta-analysis.  Pediatrics. 2011a; 127(1):119-128.
  12. Tasian GE, Copp HL, Baskin LS. Diagnostic imaging in cryptorchidism: utility, indications, and effectiveness. J Pediatr Surg. 2011b; 46(12):2406-2413.
  13. Vijayaraghavan SB. Sonographic differential diagnosis of acute scrotum: real-time whirlpool sign, a key sign of torsion. J Ultrasound Med. 2006; 25(5):563-574.
  14. Wilbert DM, Schaerfe CW, Stern WD, et al. Evaluation of the acute scrotum by color-coded Doppler ultrasonography. J Urol. 1993; 149(6):1475-1477.
  15. Yagil Y, Naroditsky I, Milhem J, et al. Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. J Ultrasound Med. 2010; 29(1):11-21.
  16. Yazbeck S, Patriquin HB. Accuracy of Doppler sonography in the evaluation of acute conditions of the scrotum in children. J Pediatr Surg. 1994; 29(9):1270-1272.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American College of Radiology. ACR–AIUM–SPR–SRU Practice Parameter for the Performance of Scrotal Ultrasound Examinations Res. 35 – 2015. Available at: https://www.acr.org/~/media/1AEC8A3D8B9B4B84A2C0394509D9E92D.pdf . Accessed on April 28, 2017.
  2. American Institute of Ultrasound in Medicine. AIUM practice guideline for the performance of scrotal ultrasound examinations. 2015. Available at: http://www.aium.org/resources/guidelines/scrotal.pdf. Accessed on April 28, 2017.
  3. NCCN Clinical Practice Guidelines in Oncology™ (NCCN). © 2011 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website at: http://www.nccn.org/index.asp. Accessed on February 12, 2015.
    • Testicular Cancer (V2.2017). Revised December 8, 2016.
History

Status

Date

Action

Reviewed 05/04/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Updated formatting in Clinical Indications section. Updated Rationale and References sections.
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 References sections. Removed ICD-9 codes from Coding section.
Reviewed 05/07/2015 MPTAC review. Updated Rationale and References sections.
Reviewed 05/15/2014 MPTAC review. No change to clinical indications. Updated References section.
New 05/09/2013 MPTAC review. Initial document development.