Does P83.5 require prior authorization?

No, P83.5 does not require prior authorization (high confidence). Covered without prior authorization.

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`P83.5`, Congenital hydrocele

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Documentation of the clinical indication that justifies the ultrasound (e.g., scrotal mass, suspected torsion, acute scrotal pain/swelling, trauma, infertility evaluation, hydrocele, varicocele, non-palpable testes with specific qualifying circumstances such as phenotypically male infant with bilateral non-palpable testes or obese boy where palpation is unreliable).
For suspected undescended testes: clinical examination findings (e.g., non-palpable testis, laterality) and documentation of why imaging is being performed (for example: to look for gonads/uterus in phenotypically male infant with bilateral non-palpable testes or to inform surgical approach in obese boys).
For suspected testicular torsion: documentation of acute scrotal symptoms (onset, severity), physical exam findings, and urgency of evaluation.

Key Coverage Criteria

- N50.811 - N50.819 Testicular pain
- N50.82 Scrotal pain [note: policy flags NOT covered for testicular microlithiasis — see limitations]
- P83.5 Congenital hydrocele
- Q53.00 - Q53.9 Undescended and ectopic testicle
- Q55.22 Retractile testis
- Q55.23 Scrotal transposition

3 Active Policies

ANTHEM-CG-RAD-27, Scrotal Ultrasound

CIGNA-0548, Scrotal Ultrasound

AETNA-CPB-0532, Scrotal Ultrasonography

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When ordering ultrasound for evaluation of possible testicular microlithiasis, documentation must include presence of additional risk factors (cryptorchidism, testicular atrophy <12 ml, prior testicular cancer) to justify surveillance; absence of these risk factors should be documented if ultrasound surveillance is nevertheless requested (note: policy states surveillance without risk factors is experimental/investigational and not covered).

P83.5, Congenital hydrocele