CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABOO9

Testosterone laboratory testing — reimbursement criteria

Defines BCBSNM reimbursement criteria for serum testosterone and related laboratory tests, and who may be eligible for payment under the plan's lab management rules.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTestosterone laboratory testing — reimbursement criteria

Policy CodePolicy CPCPLABOO9

Change TypeAdded measurement and assay guidanceclarified frequencies

Effective DateAug 15, 2023

Next Review Date

Key ActionSubmit claims with appropriate documentation and valid HIPAA-approved codes; ensure medical necessity per reimbursable indications.

SourceLink

POLICY UPDATE CHANGES

Added initial screening and follow-up screening language to measurement recommendations.

Added Note 1 specifying early morning, fasting sample collection for serum total testosterone.

Added Note 2 about assay sensitivity when measuring serum total testosterone in females.

twoinitial male screening measurements

60minimum follow-up interval (days)

2-3 momonitoring first year

annualmonitoring thereafter

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria

Reimbursable Indications and Monitoring

Covered when meeting the following reimbursable indications:

Initial male screening: Measurement of serum total testosterone for initial screening of males with symptoms of androgen deficiency or androgen excess: two measurements at least 24 hours apart.two measurements >=24 hours apart

chunk 3

Follow-up after normal initial screen: If the initial screening was normal but symptoms persist, follow-up serum total testosterone testing is allowed no sooner than 60 days after the initial screening.>=60 days

chunk 3

Monitoring on testosterone replacement therapy: For men receiving testosterone replacement therapy: measurement of serum total testosterone every 2-3 months for the first year after initiation of therapy or after a change in therapeutic dosage; annually thereafter.every 2-3 months then annually

chunk 3

Monitoring during prostate cancer enzyme inhibitor therapy: Measurement of serum total testosterone for monitoring treatment response in men taking enzyme inhibitors for prostate cancer.as clinically indicated

chunk 3

Gender-affirming care: Baseline, during treatment, and for therapy monitoring for gender-dysphoric/gender-incongruent persons.as clinically indicated

chunk 3

Symptomatic females with androgen excess: Measurement of serum total testosterone for symptomatic females being evaluated for conditions associated with androgen excess (e.g., polycystic ovary syndrome, functional hypothalamic amenorrhea).as clinically indicated

chunk 3

Assessment when SHBG altered or suspected: For individuals suspected of having disorders accompanied by increased or decreased SHBG, measurement of serum free testosterone using a medically accepted algorithm based on total serum testosterone, SHBG, and/or albumin, or measurement of bioavailable testosterone, may be reimbursable.as clinically indicated

chunks 3,4

Suspected 5-alpha reductase deficiency: For individuals with ambiguous genitalia, hypospadias, or microphallus, measurement of serum dihydrotestosterone for diagnosis of 5-alpha reductase deficiency may be reimbursable.single test as clinically indicated

chunk 3

Estradiol prior to testosterone therapy in gynecomastia: Prior to initiating testosterone therapy for males with gynecomastia, a once-per-lifetime serum estradiol measurement may be reimbursable.one lifetime

chunk 3

Measurement of serum testosterone for the purpose of identifying androgen deficiency in women is explicitly not reimbursable under this policy.

The use of saliva specimens for measurement of testosterone is not reimbursable.

Measurement of serum dihydrotestosterone is not reimbursable except for the specific situations described elsewhere in the policy (for example, when used to evaluate suspected 5‑alpha reductase deficiency).

Testing of serum total, free, or bioavailable testosterone in asymptomatic individuals or for non-specific symptoms is considered not reimbursable (not medically necessary) per the policy.

Covered Indications

Initial evaluation of men with symptoms of androgen deficiency or excess

Required measurements: Two serum total testosterone measurements obtained at least 24 hours apart for initial evaluation of males with signs or symptoms of androgen deficiency or androgen excess.

chunk 3

Monitoring men on testosterone replacement therapy

Monitoring frequency: For men receiving testosterone replacement therapy: measure serum total testosterone every 2–3 months during the first year after initiation of therapy or after a dosage change; thereafter, measure annually.every 2-3 months then annually

chunk 3

Evaluation/monitoring of gender-dysphoric/gender-incongruent persons

Coding

Covered CPT/HCPCS CodesmixedCovered

84403	Testosterone; total
84402	Testosterone; free
84146	Testosterone; bioavailable (or free?) - commonly used for dihydrotestosterone?
82570	Creatinine (often billed with testosterone panels)
82728	Sex hormone binding globulin (SHBG)
82670	Estradiol
83912	Dihydrotestosterone (if available)

Documentation Required

Prior authorization / Provider actions and denial triggers

No prior authorization is required for laboratory measurement of testosterone and related assays when billed with the covered indications in this policy. However, claims may be denied if documentation does not support a listed medical indication, or if testing frequency exceeds the stated intervals (e.g., follow-up testing performed sooner than 60 days after a normal screen, or monitoring intervals for therapy are not met).

No prior authorization required for covered indications
Denial triggers: missing clinical documentation of indication; testing performed before 60‑day follow-up interval; monitoring frequency outside stated schedules

Provider Actions & Billing

Documentation Required

Submit accurate documentation and valid HIPAA codes

Providers must submit accurate documentation of services performed and submit claims using valid HIPAA-approved code sets; additional documentation may be requested upon claim review.

Use valid HIPAA-approved code combinations (CPT, HCPCS, ICD-10, NDC, DRG, etc.) and follow industry coding guidelines.
Be prepared to provide additional documentation upon request for claim review.

Denial Risk

Denial risk for asymptomatic or saliva testing

Claims may be denied when testing is performed for asymptomatic individuals, for non-specific symptoms, or when saliva-based testosterone testing is used, as these uses are not reimbursable under this policy.

Measurement of serum total, free, or bioavailable testosterone for asymptomatic individuals or non-specific symptoms is not reimbursable.
Use of saliva for measurement of testosterone is not reimbursable.

Frequency Limits

inv-22: serum total testosterone — 2 measurements

Required measurements2 measurements for initial screening (see indications)

Preferred assay guidanceUse CDC HoSt/Testosterone certified assays for serum total testosterone when available

TimingEarly morning, after fasting (see Note 1)

inv-23: serum total testosterone follow-up interval — >= 60 days

Minimum interval before follow-up after normal initial screen>= 60 days

Applies toSerum total testosterone follow-up when initial screen normal but symptoms persist

Related rule

Definitions

inv-15: Serum total testosterone measurement — recommended early morning after fasting; CDC HoSt certified assays preferred

Timing of collectionEarly morning after fasting (NOTE 1)

Assay certificationIt is STRONGLY RECOMMENDED that serum total testosterone be measured with an assay certified by the CDC HoSt/Testosterone program

Assay sensitivity for femalesAssay technology must be sensitive enough to detect low serum total testosterone levels normally found in females (NOTE 2)

inv-16: Free or bioavailable testosterone — calculated or measured when SHBG or albumin abnormalities suspected or for further evaluation

When to measureCalculate or measure free or bioavailable testosterone when SHBG or albumin abnormalities are suspected or for further evaluation of hypogonadism

Method

Ordering Requirements

Billing Rule

Ordering and claim submission requirements

Submit claims with appropriate clinical documentation and correct coding; the policy does not restrict which clinician types may order the tests but requires that services meet medical necessity per the reimbursable indications.

Include clinical rationale linking the test to a reimbursable indication.
Follow stated frequency rules (e.g., two initial measurements ≥24 hours apart; follow-up ≥60 days).

Not Covered

Salivary testosterone testing and most uses of serum dihydrotestosterone outside the policy's specified, clinically justified indications are not covered and are therefore not reimbursable.

Testing performed for screening of asymptomatic individuals or for evaluation of vague or non‑specific symptoms (including measurement of total, free, or bioavailable testosterone) is not covered.

Measurement of serum testosterone for the identification of androgen deficiency in women is specifically listed as not covered.

Background

Measurement of serum total testosterone, and when clinically indicated free or bioavailable testosterone, is used to evaluate androgen deficiency or excess and to monitor therapy. The policy requires that serum total testosterone sampling be performed in the early morning after fasting, and it strongly recommends use of assays certified by the CDC HoSt/Testosterone program. When measuring testosterone in females, the assay technology must be sufficiently sensitive to detect the normally low serum total testosterone concentrations.