Does R39.84 require prior authorization?

No, R39.84 does not require prior authorization (high confidence). Covered without prior authorization.

`R39.84`, Bilateral non-palpable testicles

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

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.

- 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

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

ANTHEM-CG-LAB-26, Outpatient Alpha-Fetoprotein Testing

AETNA-CPB-0532, Scrotal Ultrasonography

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