From the Guidelines
For a 69-year-old with a testosterone level of 1377 ng/dL, a CT scan of the adrenal glands with and without contrast is medically necessary and should be approved by insurance. The criteria for approval typically includes documentation of significantly elevated testosterone levels, the patient's age, and clinical suspicion of an adrenal tumor or pathology, as supported by the American College of Radiology appropriateness criteria 1. To secure approval, the ordering physician should clearly document the abnormally high testosterone level, any associated symptoms (such as recent onset of virilization, hypertension, or other hormonal abnormalities), and specifically note that the elevated testosterone raises concern for an adrenal source such as an adrenocortical tumor or adrenal hyperplasia.
Some key points to consider when evaluating the need for a CT scan of the adrenal glands include:
- The size of the adrenal mass, with larger lesions being more concerning for malignancy 1
- The density of the adrenal mass on non-contrast CT, with masses having a density of less than 10 HU being more likely to be benign 1
- The use of delayed enhanced CT, which can help distinguish between adenomas and metastases 1
- The importance of characterizing adrenal masses to distinguish between benign and potentially malignant lesions, as some conditions like adrenocortical carcinoma can be aggressive and time-sensitive 1
A peer-to-peer review between the ordering physician and the insurance company's medical director may be necessary to explain the medical necessity. This imaging is crucial because adrenal pathology producing excess androgens requires prompt evaluation. The contrast portion of the study is particularly important for characterizing adrenal masses and distinguishing between benign and potentially malignant lesions, as supported by the highest quality study 1.
From the Research
Criteria for Approving CT Adrenals with and without Contrast
To approve the CT adrenals with and without contrast for a 69-year-old patient with a testosterone level of 1377, the following criteria can be considered:
- The patient's high testosterone level, which is indicative of hyperandrogenism, may be caused by an androgen-producing adrenal tumor 2
- Imaging evaluation, such as CT adrenals with and without contrast, is necessary to diagnose and guide management of adrenal-related endocrine disorders 3
- The presence of adrenal masses or incidentalomas can be associated with congenital adrenal hyperplasia (CAH) or other adrenal pathologies, which may require further evaluation and treatment 4
- The patient's age and symptoms, such as virilization, may warrant a thorough investigation of the adrenal glands to rule out any underlying conditions
Relevant Studies
- A case study of a 67-year-old postmenopausal woman with a pure testosterone-secreting adrenal adenoma highlights the importance of evaluating the adrenal glands in women with virilization, even if their androstenedione, DHEA, and DHEAS levels are normal 2
- A review of imaging techniques for adrenal-related endocrine disorders emphasizes the need for clinical and biochemical workup associated with imaging evaluation to reach a diagnosis and guide management 3
- A case report of a 61-year-old male with prostate cancer and massive adrenal myelolipomas underscores the importance of considering congenital adrenal hyperplasia in patients with non-suppressed testosterone despite androgen deprivation therapy 4
Key Points
- High testosterone levels can be caused by adrenal tumors or other pathologies
- Imaging evaluation, such as CT adrenals with and without contrast, is necessary for diagnosis and management
- Adrenal masses or incidentalomas can be associated with underlying conditions, such as CAH
- Thorough investigation of the adrenal glands is warranted in patients with symptoms of virilization or hyperandrogenism 2, 3, 4