prior authorization review panel mco policy submission a … · 2019-02-25 · scrotal...
TRANSCRIPT
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 1 of 18
Scrotal Ultrasonography
Policy History
Last Review: 10/10/2018
Effective: 08/21/2001
Next Review: 05/23/2019
Review History
Definitions
Additional Information
Clinical Policy Bulletin
Notes
Number: 0532
Policy *Please see amendment forPennsylvaniaMedicaid at theend of this CPB.
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 in either of
the following:
(i) to look for gonads or a uterus in a phenotypically
male infant with bilateral non-palpable testes (to
evaluate the possibility of disorder of sexual
development); and (ii) in obese boys, in whom intra
canalicular testes may be difficult to palpate and would
change the surgical approach (from laparoscopic to
inguinal); or
▪ Diagnosis of suspected testicular torsion; or
▪ Evaluation of hydroceles; or
▪ Evaluation of infertile men; or
10/23/2018
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 2 of 18
▪ Evaluation of scrotal pain and/or swelling (acute scrotal
symptoms); or
▪ Evaluation of scrotal injury/trauma; or
▪ Evaluation of varicoceles.
Aetna considers scrotal ultrasonography experimental and
investigational for surveillance of testicular microlithiasis in the
absence of additional risk factors (e.g., a history of
cryptorchidism or testicular atrophy (less than 12 ml), previous
testicular cancer).
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
10/23/2018
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 3 of 18
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.
Serter et al (2006) noted that testicular microlithiasis (TM) is a
rare, usually asymptomatic finding of the testes associated with
various genetic anomalies and infertility. It is believed that TM
is strongly associated with testicular tumor. In a
prospective study, these researchers determined the
prevalence of TM in an asymptomatic population by means of
ultrasound screening. Healthy male volunteers (17 to 42 years
old) were recruited from the annual Army Reserve Officer
Training Corps training camp at Manisa, Turkey. A screening
genito-urinary history was obtained and a physical
examination and screening scrotal ultrasound scan were
performed. All men diagnosed with TM underwent complete
clinical evaluations, physical examinations and determination
of tumor markers. A total of 53 men with TM were identified
from the 2,179 ultrasound scans, giving a prevalence of TM of
10/23/2018
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 4 of 18
2.4 % in this asymptomatic population. The age (mean ± SD)
of subjects with TM was 23.9 ± 4.2 years (range of 20 to 31
years). The authors concluded that these findings suggested
that there is no significant association between TM and
testicular cancer, although it is difficult to rule out such an
association without further studies with a longer follow-up
period.
DeCastro and colleagues (2007) stated that TM is an imaging
entity of the testicle with questionable significance as a marker
for testicular cancer. In 2001 these investigators reported on a
large prospective screening study establishing the prevalence
of TM to be 5.6 % in a healthy asymptomatic population of
Army volunteers 18 to 35 years old. In contrast, testicular
cancer develops in only 5 of 100,000 men. Two-year follow-up
of 63 of the 84 patients with TM showed that none of these
men had testicular cancer or scrotal masses. Here these
researchers reported he 5-year follow-up in this cohort of men
with TM at risk for testicular cancer. According to the original
parameters of the screening study these investigators
performed a history, genito-urinary examination and scrotal
ultrasound on 1,504 healthy army volunteers 18 to 35 years
old. Testicular microlithiasis was defined as greater than 6
echogenic signals found on ultrasound. They identified 84
patients with TM (5.6 %). These men were entered into the
follow-up phase of the study and instructed regarding testicular
self-examination and the need for follow-up. They were told to
report any changes in their examination or a finding of
testicular mass or cancer. Five years after the initial screening
study, the authors attempted to contact all remaining 84 men
by e-mail, standard mail and telephone. Of the original 84
men with TM identified in the original screening study, 63 have
been contacted via e-mail and by telephone (75 %). Of the 63
subjects, a mixed germ cell tumor developed in 1 patient 64
months after the initial screening study. Compared to the
incidence of testicular cancer in the general population the
odds ratio of developing testicular cancer in this study
population was 317 (95 % confidence interval [CI]: 36 to
10/23/2018
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 5 of 18
2,756). The authors concluded that testicular cancer will not
develop in the majority of men with TM (98.4 %) during a
5-year follow-up interval. They believed that an intensive
screening program for men with TM is not cost-effective and
would do little to improve outcomes associated with testicular
cancer. These investigators continued to recommend
testicular self-examination in men at risk.
In a retrospective study, Chen and colleagues (2010)
determined the incidence of TM in Taiwanese males who were
referred for scrotal ultrasonography (US) and evaluated the
association between TM and cancer, with state-of-the-art
equipment. A total of 513 males who underwent scrotal US in
a period of 7 months were included in this study. The US
images and charts of each patient were reviewed to determine
the presence of TM and note relevant clinical information. The
data for all 513 patients were analyzed. Their age was 0 to 91
years (mean of 54.3 years). The overall incidence of TM was
14.4 % (74/513); 6.2 % (32/513) had classic TM, and 8.2 %
had limited TM. The incidence of testicular cancer in this
population was 1.6 % (8/513). Six of 8 (75 %) patients who
had testicular cancer at presentation had classic TM or limited
TM. There was a significant difference (p < 0.01) between the
rate of malignancy in subjects with TM (6/74) and that in
subjects without TM (2/439). The authors concluded that the
incidence of TM in Taiwanese people may be higher than
previously reported, which may be due to the difference in
methodology and increased awareness of the US findings.
Moreover, they stated that although there was a significant
difference in the rate of malignancy in males with TM
compared with those without TM, the question remains
whether TM independently increases the risk of testicular
malignancy.
Dutra et al (2011) evaluated the prevalence of TM among
pediatric patients with inguino-scrotal affections. Between
January 2005 and January 2010, these investigators
evaluated, prospectively 1,504 children ranging from 1 to 15
10/23/2018
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 6 of 18
years with inguino-scrotal affections with a high-frequency
ultrasound system, which employs a 10-MHz transducer.
Testicular microlithiasis was identified in 20 testes of 11
children (0.71 % of 1,504 patients evaluated), through an
ultrasound scan. Testicular microlithiasis was found in 5
children with cryptorchidism (3.93 % of 127 patients), 4
children with retractile testes (14.8 % of 27 patients), 1 child
with a hypotrophic testis (100 % of 1 patient), and 1 child with
inguinal hernia (0.07 % of 1,349 patients). The children with
TM were submitted to annual physical examinations and
ultrasound evaluations. The authors concluded that TM was a
rare condition and occurred in 0.7 % of the subjects studied.
The association with cryptorchidism, retractile and hypotrophic
testis was significant.
Richenberg et al (2012) stated that ultrasound surveillance of
patients with TM has been advocated following the reported
association with testicular cancer. These researchers
evaluated the evidence supporting such surveillance. Formal
literature review identified cohort studies comprising at least
15 patients followed-up for at least 24 months. Combining an
institutional audit with the identified studies in a pooled
analysis the incidence of new cancers during the surveillance
period was evaluated. Literature review identified 8 studies.
The authors’ institutional audit comprised 2,656 men referred
for scrotal ultrasound. Fifty-one men (1.92 %) with TM were
identified, none of whom developed testicular cancer (mean
follow-up: 33.3 months). In a combined population of 389 men
testicular cancer developed in 4. Excluding 3 who had
additional risk factors, only 1 of 386 developed testicular
cancer during follow-up (95 % confidence interval: 0.05 5 to
1.45 %). The authors concluded that ultrasound surveillance is
unlikely to benefit patients with TM in the absence of other
risk factors. In the presence of additional risk factors (a history
of cryptorchidism or testicular atrophy, previous testicular
cancer) patients are likely to be under surveillance;
10/23/2018
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 7 of 18
nonetheless monthly self-examination should be encouraged,
and open access to ultrasound and formal annual surveillance
should be offered.
An UpToDate review on “Screening for testicular cancer” (Lin,
2014) states that “Testicular microlithiasis is a common finding
during infertility evaluations, but its association with testicular
cancer is controversial. Microlithiasis has been detected with
scrotal ultrasonography in up to 5 percent of healthy
adolescents and young men”.
Shetty et al (2014) examined if there is a consensus regarding
the significance of TM and a strategy for managing patients
with this condition, among ultrasound practitioners in the
United Kingdom (U.K.). An electronic questionnaire was
distributed to 1,482 members of the British Medical Ultrasound
Society (BMUS), requesting information from ultrasound
practitioners involved in scrotal ultrasound about their
interpretation of the risk associated with TM and their
departmental or personal recommendations for managing
patients with this condition. Responses were obtained from
221 BMUS members. Analysis demonstrated a wide variation
in the significance attributed to the discovery of TM and the
risk of subsequent development of testicular germ cell tumors.
There was also great variation in strategies for management of
patients with TM, including the need for surveillance
ultrasound, among ultrasound practitioners regardless of their
job description. The authors concluded that lack of consensus
shown by this study highlights significant differences across
the U.K. in managing patients with TM and validates the
importance of guidance currently being formulated by the
European Society of Urogenital Radiology. These researchers
believe that this is the first survey conducted among imaging
specialists in the U.K. regarding TM and demonstrates that
there is currently no uniform practice in managing patients with
this condition.
10/23/2018
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 8 of 18
Furthermore, the European Association of Urology’s clinical
practice guidelines on “Testicular cancer” (Albers et al, 2011)
stated that “In the absence of other risk factors (less than 12
ml (atrophy), maldescent testis), testicular microlithiasis is not
an indication for biopsy or further (ultrasound) screening”.
Volokhina and colleagues (2014) noted that there is
suggestion that testicular microlithiasis predicts risk of
testicular malignancy, especially testicular germ cell tumors.
This association remains uncertain. These investigators
retrospectively reviewed testicular germ cell tumor occurrence
in patients with testicular microlithiasis to assess this
association and determined the prevalence of testicular
microlithiasis in symptomatic boys. This study was IRB and
HIPAA compliant. A total of 2,625 testicular US exams
performed on 2,266 children (younger than 19 years of age) in
the authors’ institution from 2000 through 2011 were reviewed
for presence of testicular microlithiasis and masses. Testicular
microlithiasis was defined as presence of 5 or more testicular
microcalcifications on a single US image. Incidence of
testicular germ cell tumors was calculated in a group of
patients with testicular microlithiasis and in a control group
without testicular microlithiasis. Relative risk, odds ratio, 90 %
and 95 % CI were calculated. A total of 87 patients out of
2,266 had testicular microlithiasis. One child was found to
have both testicular germ cell tumor and testicular
microlithiasis. In 2,179 children without testicular
microlithiasis, 8 had testicular germ cell tumors. Incidence of
testicular microlithiasis was 3.8 %. Incidence of testicular
germ cell tumors in testicular microlithiasis patients was 1.2 %,
and 0.38 % in non-testicular microlithiasis patients. Relative
risk of testicular germ cell tumors in testicular microlithiasis
patients versus non-testicular microlithiasis patients was 3.13
(90 % CI: 0.55 to 17.76; 95 % CI: 0.40 to 24.76), odds ratio
(OR) 3.16 (90 %CI: 0.55 to 18.32; 95 % CI: 0.39 to 25.5). The
authors concluded that there is no association between
testicular microlithiasis and testicular germ cell tumors. These
10/23/2018
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 9 of 18
investigators had hoped to do a meta-analysis, but only 2
studies had a sufficient case control group of non-testicular
microlithiasis patients.
Testicular Microlithiasis
Richenberg et al (2015) stated that the subcommittee on
scrotal imaging, appointed by the board of the European
Society of Urogenital Radiology (ESUR), have produced
guidelines on imaging and follow-up in testicular micro-lithiasis
(TML). The authors and a superintendent university librarian
independently performed a computer-assisted literature search
of medical databases: MEDLINE and EMBASE. A further
parallel literature search was made for the genetic conditions
Klinefelter's syndrome and McCune-Albright syndrome.
Proposed guidelines were: follow-up is not advised in patients
with isolated TML in the absence of risk factors; annual US is
advised for patients with risk factors, up to the age of 55; if
TML is found with a testicular mass, urgent referral to a
specialist center is advised. The authors concluded that
consensus opinion of the scrotal subcommittee of the ESUR is
that the presence of TML alone in the absence of other risk
factors is not an indication for regular scrotal US, further US
screening or biopsy. Ultrasonography is recommended in the
follow-up of patients at risk, where risk factors other than
microlithiasis are present.
Undescended (Cryptorchid) Testes
Kanaroglou et al (2015) stated that there is a limited role for
ultrasound in the management of an undescended testicle
(UDT). These investigators hypothesized that ultrasound
remains over-used by referring physicians; they characterized
the trends, patterns, and impact of ultrasound use for UDT and
re-affirmed its limited diagnostic value for this indication. The
records of boys aged 0 to 18 years with UDT in Ontario,
Canada, between 2000 and 2011 were reviewed by using
health administrative data housed at the Institute for Clinical
10/23/2018
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 10 of 18
and Evaluative Sciences (ICES). A second review of boys
referred to the authors’ institution with UDT between 2007 and
2011 was conducted to complement the health administrative
data. Trends in frequency, distribution, and costs of
ultrasound use were assessed. Time delays between
diagnosis and definitive management were compared between
the ultrasound and non-ultrasound groups. Using the authors’
institutional data, these researchers analyzed demographic
patterns of ultrasound use and compared its diagnostic
accuracy by using surgical findings as the gold standard.
Ultrasound was used in 33.5 % of provincial referrals and 50
% of institutional referrals. Children who underwent ultrasound
experienced an approximate 3-month delay in definitive
surgical management. Ultrasound correctly predicted physical
examination findings in only 54 % of patients. Physicians in
community practice, and those with fewer years in practice,
were more likely to order ultrasound. The authors concluded
that ultrasound has limited value for the management of UDT
but remains widely over-used, with an increasing trend over
time. They stated that this practice has negative implications
for access to care and cost-containment; wide-spread
educational efforts should be undertaken, targeting current and
future referring physicians.
Furthermore, an UpToDate review on “Undescended testes
(cryptorchidism) in children: Clinical features and
evaluation” (Cooper and Docimo, 2015) states that “Imaging is
not routinely warranted to locate non-palpable testes. Imaging
studies lack the sensitivity and the specificity to alter the need
for exploratory surgery. In a systematic review, the sensitivity
and specificity of ultrasonography in detecting non-palpable
testes were 45 and 78 %, respectively. In contrast, the
sensitivity and specificity of exploratory surgery are nearly 100
%.
Imaging may be necessary to evaluate conditions in the
differential diagnosis or for surgical planning. As examples:
10/23/2018
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 11 of 18
• Ultrasonography may be indicated to look for gonads or
a uterus in a phenotypically male infant with bilateral
non-palpable testes (to evaluate the possibility of
disorder of sexual development).
• Ultrasonography may be warranted in obese boys, in
whom intra-canalicular testes may be difficult to palpate
and would change the surgical approach (from
laparoscopic to inguinal). In a systematic review of the
literature, the accuracy of ultrasonography in identifying
inguinal or scrotal testes was 92 %, but the included
studies were of poor quality and lacked important
clinical information (e.g., position of contralateral testis,
associated clinical findings, etc.)”.
Testicular Torsion
McDowall and colleagues (2018) stated that a positive
whirlpool sign (WS) is defined as the presence of a spiral-like
pattern when the spermatic cord is assessed during US, using
standard, high-resolution US(HRUS) and/or color Doppler
sonography (CDS), in the presence of testicular torsion (TT).
These investigators evaluated the validity and accuracy of this
sign by performing a comprehensive systematic literature
review and meta-analysis. In accordance with the Preferred
Reporting Items for Systematic Reviews and Meta-analyses
(PRISMA) guidelines, a comprehensive literature search was
performed (August, 2017), using the following databases: BMJ
Best Practice, Cochrane Library, Embase, PubMed, Scopus,
and Web of Science. Selected studies were further assessed
for relevance and quality using the Oxford 2010 Critical
Appraisal Skills Program (CASP). Of the studies assessed, a
total of 723 participants were included, with a mean of 72.3
(SD 71.9) participants. Of the participants, 226 (31.3 %) were
diagnosed with TT. Meta-analysis of the studies that provided
sufficient data resulted in a pooled sensitivity and specificity of
the WS of 0.73 (95 % CI: 0.65 to 0.79) and 0.99 (95 % CI: 0.92
to 0.99), respectively. Removal of all neonates increased the
pooled sensitivity to 0.92 (95 % CI: 0.70 to 0.98) while the
10/23/2018
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 12 of 18
pooled specificity remained almost unchanged at 0.99 (95 %
CI: 0.95 to 1.00). The estimated summary effect of all studies
with sufficient data was 4.34 (95 % CI: 1.01 to 7.67; n = 394; p
= 0.001). A large degree of heterogeneity was suggested by
an I2 statistic of 88.27 % (95 % CI: 68.60 to 98.68 %).
Removal of neonatal subjects increased the estimated
summary effect to 5.32 (95 % CI: 1.59 to 9.05; n = 375;
p = 0.001). The authors concluded that the WS, when
correctly diagnosed, may be viewed as a very definitive sign
for TT in the pediatric and adult populations; however, its
role in neonates is limited.
CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":
Code Code Description
CPT codes covered if selection criteria are met:
76870 Ultrasound, scrotum and contents
ICD-10 codes covered if selection criteria are met:
C63.2 Malignant neoplasm of scrotum
D29.4 Benign neoplasm of scrotum
D40.10 -
D40.12
Neoplasm of uncertain behavior of testis
I86.1 Scrotal varices
N43.0 -
N43.42
Hydrocele and spermatocele
N44.00 -
N44.04
Torsion of testis
N45.1 -
N45.4
Orchitis and epididymitis
10/23/2018
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 13 of 18
Code Code Description
N46.01 - Male infertility
N50.0 Atrophy of testis
N50.811 -
N50.819
Testicular pain
N50.82 Scrotal pain [not covered for testicular
microlithiasis]
P83.5 Congenital hydrocele
Q53.00 -
Q53.9
Undescended and ectopic testicle
Q55.22 Retractile testis
Q55.23 Scrotal transposition
R39.83 -
R39.84
Non-palpable testicle
S39.848+ Other specified injuries of external genitals
[scrotal trauma]
S39.94X+ Unspecified 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.
10/23/2018
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 14 of 18
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.
10/23/2018
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 15 of 18
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
10/23/2018
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 16 of 18
in Ultrasound. AIUM practice guideline for the
performance of scrotal ultrasound examinations. J
Ultrasound Med. 2011;30(1):151-155.
29. Oto A, Yacoub JH, Casalino DD, et al; Expert Panel on
Urologic Imaging. ACR Appropriateness Criteria staging
of testicular malignancy [online publication]. Reston,
VA: American College of Radiology (ACR); 2012.
30. Serter S, Gumus B, Unlu M, et al. Prevalence of
testicular microlithiasis in an asymptomatic
population. Scand J Urol Nephrol. 2006;40(3):212-214.
31. DeCastro BJ, Peterson AC, Costabile RA. A 5-year
followup study of asymptomatic men with testicular
microlithiasis. J Urol. 2007;179(4):1420-1423;
discussion 1423.
32. Chen JL, Chou YH, Tiu CM, et al. Testicular
microlithiasis: Analysis of prevalence and associated
testicular cancer in Taiwanese men. J Clin Ultrasound.
2010;38(6):309-313.
33. Dutra RA, Perez-Boscollo AC, Melo EC, Cruvinel JC.
Clinical importance and prevalence of testicular
microlithiasis in pediatric patients. Acta Cir Bras.
2011;26(5):387-390.
34. Albers P, Albrecht W, Algaba F, et al; European
Association of Urology. EAU guidelines on testicular
cancer: 2011 update. Eur Urol. 2011;60(2):304-319.
35. Richenberg J, Brejt N. Testicular microlithiasis: Is there
a need for surveillance in the absence of other risk
factors? Eur Radiol. 2012;22(11):2540-2546.
36. Shetty D, Bailey AG, Freeman SJ. Testicular
microlithiasis an ultrasound dilemma: Survey of
opinions regarding significance and management
amongst UK ultrasound practitioners. Br J Radiol.
2014;87(1034):20130603.
37. Lin KW. Screening for testicular cancer. UpToDate
[online serial]. Waltham, MA: UpToDate; reviewed
March 2014.
38. Isidori AM, Pozza C, Gianfrilli D, et al. Differential
diagnosis of nonpalpable testicular lesions: Qualitative
10/23/2018
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 17 of 18
and quantitative contrast-enhanced US of benign and
malignant testicular tumors. Radiology. 2014;273
(2):606-618.
39. Volokhina YV, Oyoyo UE, Miller JH. Ultrasound
demonstration of testicular microlithiasis in pediatric
patients: Is there an association with testicular germ
cell tumors? Pediatr Radiol. 2014;44(1):50-55.
40. Richenberg J, Belfield J, Ramchandani P, et al.
Testicular microlithiasis imaging and follow-up:
Guidelines of the ESUR scrotal imaging subcommittee.
Eur Radiol. 2015;25(2):323-330.
41. Kanaroglou N, To T, Zhu J, et al. Inappropriate use of
ultrasound in management of pediatric
cryptorchidism. Pediatrics. 2015;136(3):479-486.
42. Cooper CS, Docimo SG. Undescended testes
(cryptorchidism) in children: Clinical features and
evaluation. UpToDate [online serial]. Waltham, MA:
UpToDate; reviewed March 2016.
43. Kuhn AL, Scortegagna E, Nowitzki KM, Kim YH.
Ultrasonography of the scrotum in adults.
Ultrasonography. 2016;35(3):180-197.
44. Lorenc T, Krupniewski L, Palczewski P, Gołebiowski M.
The value of ultrasonography in the diagnosis of
varicocele. J Ultrason. 2016;16(67):359-370.
45. Churukanti GR, Kim A, Rich DD, et al. Role of
ultrasonography for testicular injuries in penetrating
scrotal trauma. Urology. 2016;95:208-212.
46. Jedrzejewski G, Wieczorek AP, Osemlak P, Nachulewicz
P. The role of ultrasound in the management of
undescended testes before and after orchidopexy - an
update. Medicine (Baltimore). 2016;95(51):e5731.
47. McDowall J, Adam A, Gerber L, et al. The
ultrasonographic "whirlpool sign" in testicular torsion:
Valuable tool or waste of valuable time? A systematic
review and meta-analysis. Emerg Radiol. 2018 Jan 15
[Epub ahead of print].
10/23/2018
Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna Page 18 of 18
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.
Copyright © 2001-2018 Aetna Inc.
http://aetnet.aetna.com/mpa/cpb/500_599/0532.html 10/23/2018
AETNA BETTER HEALTH® OF PENNSYLVANIA
Amendment to Aetna Clinical Policy Bulletin Number: 0532 Scrotal Ultrasonography
There are no amendments for Medicaid.
www.aetnabetterhealth.com/pennsylvania new 11/01/2018