Prior Authorization Review Panel MCO Policy Submission A … · 2019-02-25 · Scrotal...

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Scrotal Ultrasonography - Medical Clinical Policy Bulletins | Aetna 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

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▪ 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

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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

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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

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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

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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;

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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.

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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

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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

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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:

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• 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

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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

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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:

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2. Dewbury K. Scrotal ultrasound. Br J Hosp Med. 1997;57

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3. Hamm B. Differential diagnosis of scrotal masses by

ultrasound. Eur Radiol. 1997;7(5):668-679.

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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

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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.

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Doppler imaging of the testes. World J Urol. 1998;16

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of testicular tumors and tumor-like conditions: A

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scrotal ultrasound advantageous in infertile men? J

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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.

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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.

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imaging findings, and management. Radiographics.

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20. Lee JC, Bhatt S, Dogra VS. Imaging of the epididymis.

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d'andrologie de l'association française d'urologie

(CCAFU). Optimal evaluation of the infertile male. 2007

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trauma. Radiographics. 2008;28(6):1617-1629.

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ultrasonography in diagnosis of testicular rupture

after blunt scrotal trauma. Urology. 2008;71(1):52-56.

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abnormalities in adults: An update. Diagn Interv

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sonography revisited. J Clin Ultrasound. 2010;38(1):21

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ultrasound in treatment of adolescents with

varicocele. J Urol. 2010;183(5):2008-2011.

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in Ultrasound. AIUM practice guideline for the

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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

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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.

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37. Lin KW. Screening for testicular cancer. UpToDate

[online serial]. Waltham, MA: UpToDate; reviewed

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diagnosis of nonpalpable testicular lesions: Qualitative

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and quantitative contrast-enhanced US of benign and

malignant testicular tumors. Radiology. 2014;273

(2):606-618.

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demonstration of testicular microlithiasis in pediatric

patients: Is there an association with testicular germ

cell tumors? Pediatr Radiol. 2014;44(1):50-55.

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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

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[Epub ahead of print].

10/23/2018



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

http://www.aetnabetterhealth.com/pennsylvania

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