Does Q53.13 require prior authorization?

No, Q53.13 does not require prior authorization (high confidence). Covered without prior authorization.

`Q53.13`, Unilateral high scrotal testis

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Claims must be submitted with the most appropriate and applicable covered diagnosis code(s) listed in the policy; services billed without a covered diagnosis code will be denied.
Clinical documentation must support one of the listed medically necessary indications (e.g., documentation of acute scrotal pain, trauma, suspected torsion, mass, infertility evaluation, family history of testicular cancer, varicocele, hydrocele, nonpalpable testes age ≥6 months, suspected occult inguinal hernia).
A thorough history and physical examination is expected; physical exam documentation should include findings in both standing and supine positions where relevant.
For suspected inguinal (occult) hernia, documentation should indicate inability to confirm diagnosis on physical exam (including standing and Valsalva maneuver) prior to ordering scrotal ultrasound.

Acute scrotal pain or testicular torsion
Acute scrotal trauma or injury
Suspected infectious or inflammatory scrotal disease (e.g., epididymitis, orchitis, epididymo-orchitis, abscess of epididymis or testis)
Scrotal neoplasm or mass (including suspected intratesticular mass)
Family history of testicular cancer / germ cell tumor (GCT)
Scrotal varices (varicocele)

ANTHEM-CG-LAB-27, Human Chorionic Gonadotropin Testing

CIGNA-0548, Scrotal Ultrasound

Ask Backwork about documentation requirements, denial risks, or coverage in your state.