Does S30.94XA require prior authorization?

No, S30.94XA does not require prior authorization (high confidence). Covered without prior authorization.

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`S30.94XA`, Unspecified superficial injury of scrotum and testes, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

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.

For nonpalpable testes, documentation must include age (to establish ≥ six months) and nonpalpable status.

When applicable, documentation of prior indeterminate ultrasound findings or prior imaging prompting follow-up ultrasound should be included (policy references follow-up of indeterminate findings).

Key Coverage Criteria

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)

2 Active Policies

ANTHEM-CG-RAD-27, Scrotal Ultrasound

CIGNA-0548, Scrotal Ultrasound

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S30.94XA, Unspecified superficial injury of scrotum and testes, initial encounter