Vasectomy Procedures and Chronic Scrotal Content Pa… | Aetna

Vasectomy Procedures and Chronic Scrotal Content Pain

Aetna · PayerPolicy · AETNA-CPB-0027

Status: Active
Effective: March 6, 2023
Last reviewed by Aetna: January 27, 2026
Last checked by Backwork: August 1, 2026

Summary of the payer’s published policy. Not a coverage determination — confirm with Aetna before submitting.

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Codes in this policy

Each code’s status is what the policy records for it. This page does not show the policy’s criteria. Read them in the payer’s source.

Codes this policy lists and each code’s status in the policy
Code	Code system	Status in this policy
52402	CPT	Covered
54860	CPT	Covered
54861	CPT	Covered
55250	CPT	Covered
55400	CPT	Covered
89310	CPT	Covered
G89.28	ICD10CM	Covered
N50.81	ICD10CM	Covered
Z30.2	ICD10CM	Covered
Z98.52	ICD10CM	Covered