ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLAB009

Testosterone

This BCBSNM clinical payment and coding policy outlines when laboratory measurement of testosterone and related hormones is reimbursable for members and provides testing limitations and specimen/assay recommendations. It applies to providers submitting claims to Blue Cross Blue Shield of New Mexico for testosterone-related lab services.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTestosterone

Policy CodePolicy CPCPLAB009

Change TypeMaterial updates to screening, specimen timing, and assay sensitivity

Effective DateAug 15, 2023

Next Review DateN/A

Key ActionEnsure testing follows the updated requirements: initial and follow-up screening language, morning fasting specimen collection, and use of sufficiently sensitive assays for females to qualify for reimbursement.

SourceLink

POLICY UPDATE CHANGES

Initial screening and follow-up screening language was added to criterion #1a.

Note requiring serum total testosterone sample collection in the early morning after fasting was added.

Note clarifying that assays for serum total testosterone in females must be sufficiently sensitive to detect low levels.

Other reimbursement information was revised for clarity.

References were revised; some added and others removed.

multipledistinct reimbursable scenarios listed

2initial screening measurements

60follow-up minimum interval (days)

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2-3momonitoring frequency (first year)

recommendedCDC HoSt assay recommendation

3new explicit notes/requirements

Coverage Criteria

Testosterone testing coverage criteria

Covered when ALL of the following apply as specified below:

ALL of the following

May be reimbursable for
- Symptoms of androgen deficiency or androgen excess in males; initial screening requires two measurements at least 24 hours apart
- Monitoring treatment response in men taking enzyme inhibitors for prostate cancer
- Men receiving testosterone replacement therapy (every 2–3 months for the first year after initiation or after dose change; annually thereafter)
- Gender‑dysphoric/gender‑incongruent persons — baseline, during treatment, and for therapy monitoring
- Symptomatic females being evaluated for conditions associated with androgen excess (e.g., PCOS, functional hypothalamic amenorrhea)

ALL of the following

If the initial screening was normal but symptoms persist, follow-up testing allowed no sooner than 60 days after the initial screening

Coverage-related updates and specimen requirements

Policy updates and specimen/assay requirements that affect coverage determinations:

ALL of the following

Serum total testosterone samples should be collected in the early morning after fasting (Note 1)

ALL of the following

Assay technology used to measure serum total testosterone in females must be sufficiently sensitive to detect the low serum total testosterone levels normally found in females (Note 2)

ALL of the following

Initial screening language and follow‑up screening timing were added to the criteria for initial male screening (two measurements ≥24 hours apart; follow‑up no sooner than 60 days)

ALL of the following

Coding and References

Procedure codes noticemixed

Procedure code list not exhaustive; inclusion does not guarantee coverage

References and background literaturemixed

No codes listed

Assay sensitivity for females

RequirementAssay technology used for measuring serum total testosterone in females must be sufficiently sensitive to detect the low serum total testosterone levels normally found in females.

ContextAdded as a new Note 2 in the 8/15/2023 policy update to guide laboratory selection and reimbursement determinations.

ImplicationInsufficiently sensitive assays for female samples may render testing non-reimbursable.

Provider Actions and Requirements

Documentation Required

Documentation and claim review

Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid HIPAA-approved code combinations and appropriate industry-standard coding guidelines. Claims are subject to code edit protocols and claim review; upon request, providers may be required to submit additional documentation to support the claim.

Submit accurate documentation of services performed.
Use valid HIPAA-approved code sets and code appropriately per UB, CPT, HCPCS, ICD-10, NDC, DRG, CMS/NCCI guidance.
Be prepared to provide additional documentation upon request during claim review.

Note

Provider requirements and notes (policy update)

The policy was updated to add initial and follow-up screening language and to specify specimen collection timing and assay sensitivity for females; providers should ensure testing follows these requirements for reimbursement.

Initial screening and follow-up screening language was added to criterion #1a (see policy update).

Definitions and Specimen Standards

Sex terminology

DefinitionTerms such as male and female are used when necessary to refer to sex assigned at birth.

UsagePolicy language and reimbursement criteria use sex terminology tied to sex assigned at birth to describe covered scenarios.

ScopeApplies throughout the reimbursement sections describing indications (e.g., males, females, gender-dysphoric/gender-incongruent persons).

Sample collection and assay standard

Sample timingSerum total testosterone sample collection should occur in the early morning after fasting.

RecommendationAdded to Note 1 in the 8/15/2023 policy update to improve diagnostic accuracy and inform reimbursement decisions.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTestosterone

Policy CodePolicy CPCPLAB009

Change TypeMaterial updates to screening, specimen timing, and assay sensitivity

Effective DateAug 15, 2023

Next Review DateN/A

SourceLink

On This Page

References were updated to support measurement performance and clinical context (literature review reflected in policy update)

Serum total testosterone samples should be collected in the early morning after fasting.

When measuring serum total testosterone in females, use assay technology sufficiently sensitive to detect the low levels normally found in females.

Related guidanceFollow other specimen and assay requirements (e.g., CDC HoSt/Testosterone-certified assays are strongly recommended where applicable).

Morning fasting collection

TimingCollect serum total testosterone early in the morning (morning sample preferred).

Fasting stateCollect after fasting to standardize results and support accurate interpretation.

Policy changeExplicit morning fasting collection requirement was added in the 8/15/2023 update (Note 1).

Female-sensitive assay

Sensitivity standardAssays used for female serum total testosterone must detect the low concentrations that are normal in females.

Added noteThis requirement was introduced as Note 2 in the 8/15/2023 policy update to clarify allowable testing methods for females.

Reimbursement impactLaboratories and providers should ensure assay methodology meets this sensitivity requirement to support reimbursement for female testing.