Blue Cross Blue Shield - Oklahoma Testosterone Coverage

Coverage Criteria for Testosterone and Related Tests

Reimbursable indications and testing frequency

Covered when the following situation-specific criteria are met:

Primary reimbursable indications: Measurement of serum total testosterone may be reimbursable for: (a) symptoms of androgen deficiency or androgen excess in males; (b) monitoring treatment response in men taking enzyme inhibitors for prostate cancer; (c) men receiving testosterone replacement therapy; (d) gender-dysphoric/gender-incongruent persons (baseline, during treatment and for therapy monitoring); (e) symptomatic females being evaluated for conditions associated with androgen excess (e.g., PCOS, functional hypothalamic amenorrhea).

See policy items 1a-1e

Initial male screening frequency: For initial screening of males with symptoms of androgen deficiency or excess, two serum total testosterone measurements are required at least 24 hours apart.two measurements >=24 hours apart

If the initial screening was normal but symptoms persist, repeat testing allowed no sooner than 60 days after the initial screening (see policy item 1a ii).

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

See policy item 1c

Follow-up for enzyme inhibitor therapy: Measurement of serum total testosterone for monitoring treatment response in men taking enzyme inhibitors for prostate cancer is reimbursable.

See policy item 1b

Gender-affirming care monitoring: For gender-dysphoric/gender-incongruent persons, serum total testosterone measurement may be reimbursable at baseline, during treatment, and for therapy monitoring.

See policy item 1d

Symptomatic females with suspected androgen excess: For symptomatic females being evaluated for conditions associated with androgen excess (e.g., PCOS, functional hypothalamic amenorrhea), measurement of serum total testosterone may be reimbursable.

See policy item 1e; note assay sensitivity for females (Note 2)

Additional testing for confirmed low/borderline total testosterone in males: For males with total testosterone confirmed as low or borderline low and who have hypogonadism, gynecomastia, and/or other forms of testicular hypofunction, annual measurements of serum free testosterone, SHBG, and/or albumin may be reimbursable.annual

See policy item 2

SHBG-related evaluation: When a disorder accompanied by increased or decreased SHBG is suspected, measurement of serum free testosterone using a medically accepted algorithm based on total testosterone, SHBG, and/or albumin or measurement of bioavailable testosterone may be reimbursable.

See policy item 3 and Notes 3-4

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

See policy item 4

Dihydrotestosterone for congenital/genital anomalies: For individuals with ambiguous genitalia, hypospadias, or microphallus, measurement of serum dihydrotestosterone for the diagnosis of 5-alpha reductase deficiency may be reimbursable.

See policy item 5

Not reimbursable / exclusions

Primary exclusions: (a) Measurement of serum free testosterone and/or bioavailable testosterone as a primary test (i.e., without a prior serum total testosterone measurement) is not reimbursable; (b) For asymptomatic individuals or those with non-specific symptoms, measurement of serum total, free, and/or bioavailable testosterone is not reimbursable; (c) For the identification of androgen deficiency in women, measurement of serum testosterone is not reimbursable; (d) The use of saliva for testosterone measurement is not reimbursable; (e) Measurement of serum dihydrotestosterone for all other situations not specifically mentioned above is not reimbursable.

See policy items 6-10

The policy explicitly states that the use of saliva for the measurement of testosterone is not reimbursable. In addition, measurement of serum dihydrotestosterone is not reimbursable for situations other than those specifically listed (for example, ambiguous genitalia, hypospadias, or microphallus). These exclusions apply regardless of testing method or clinical setting.

No additional explicit exclusions are listed in the referenced update notes. The policy update history documents literature-review and clarification changes but does not add further exclusion language in these chunks.

Testing for serum total, free, or bioavailable testosterone in asymptomatic individuals or those with non-specific symptoms is not reimbursable. The policy therefore does not support routine or screening use of these tests without documented clinical indications consistent with the reimbursable criteria.

Within the chunks cited there are no explicit statements framed as additional 'not medically necessary' determinations beyond the exclusions already described in the policy updates; operational and literature-review notes clarify methods and collection timing but do not introduce new not-medically-necessary language in these sections.

Clinical Indications Where Testing May Be Covered

Testing for testosterone levels in clinical contexts including aging males, females, and conditions affecting serum testosterone

Testing for testosterone levels may be appropriate in multiple clinical contexts; note assay selection and sample timing considerations particularly for female measurements.

Assay and collection guidance: Serum total testosterone sample collection should occur in the early morning after fasting; it is strongly recommended that measurement be performed with an assay certified by the CDC HoSt/Testosterone program. For females, use assays with sufficient sensitivity to detect the low serum total testosterone levels normally found in females.

See Note 1 and Note 2

Clinical contexts supported by references: References support testing in contexts including aging males, dynamics in metabolic and cardiac disease, development of LC-MS/MS assays, harmonized reference ranges, and considerations for salivary versus serum measurements.

See reference list (chunks 18-21) and policy update history (chunk 22)

Frequency and Monitoring Limits

inv-23: serum total testosterone — Two measurements for initial male screening

FrequencyTwo measurements for initial male screening (at least 24 hours apart)

Clinical contextInitial screening for males with symptoms of androgen deficiency or excess

Supporting noteTerms such as male and female refer to sex assigned at birth

inv-24: serum total testosterone — If initial screening normal but symptoms persist, repeat no sooner than 60 days after initial screening

FrequencyIf initial screening normal but symptoms persist, repeat no sooner than 60 days after the initial screening

Clinical contextFollow-up testing for males with persistent symptoms after a normal initial screen

Procedure Codes and Coding Guidance

Procedure codes listedCPT

82040
82642
82670
82681
84270
84402
84403
84410

Provider Actions, Billing and Documentation

Billing Rule

Product-specific reimbursement criteria

The Plan has implemented product-specific lab management reimbursement criteria. Not all requirements apply to every product; providers should review the member's specific Plan documents (Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents) to determine eligible coverage and any product-specific reimbursement rules.

Providers are responsible for verifying member coverage and benefits prior to providing services.
When a conflict exists between this Clinical Payment and Coding Policy and a plan document or provider contract, the plan document or provider contract governs as applicable.

Note

None stated in these chunks

No prior authorization, step therapy, or other product action requirements are specified in these chunks of the source document.

Ordering Requirements and Restrictions

Note

Review Plan coverage and submit accurately coded claims with documentation

Before ordering tests, review the member’s Plan documents to confirm product-specific coverage; ensure claims are coded correctly and that accurate documentation of the services performed is available and submitted.

Confirm coverage and any product-specific limits or requirements in Plan documents.
Code claims using appropriate CPT/HCPCS/ICD-10 codes per industry guidelines and the policy's listed procedure codes.
Retain and submit supporting clinical documentation if requested.

Note

No explicit ordering restrictions stated

The policy does not state any explicit restrictions on who may order these tests. Providers should follow usual practice and any ordering restrictions specified by the member’s Plan documents or provider contract.

Tests and Indications Not Covered

The policy lists several specific tests and testing approaches that are not covered: salivary testosterone testing, primary testing with free or bioavailable testosterone without a prior serum total testosterone measurement, and testosterone testing in asymptomatic or non-specific symptom individuals. These are identified as not covered items and should not be billed as reimbursable services.

The referenced literature and methods sections in these chunks do not add further specific exclusions or single-test prohibitions beyond those already stated in the policy text. References support assay methods, reference ranges, and interpretation but do not themselves define additional not-covered items in these excerpts.

Definitions and Test Method Notes

inv-17: Total testosterone (serum) — measurement details; recommended collection early morning after fasting and preferably performed using a CDC HoSt program method

Collection timingCollect serum total testosterone in the early morning after fasting

Assay recommendationPreferably use an assay certified by the CDC HoSt/Testosterone program

ReasoningCDC HoSt-certified assays are standardized to within ±6.4% of the CDC reference standard

inv-18: Free or bioavailable testosterone — calculated or measured estimate; may be reimbursable when total is low/borderline

DefinitionCalculated or measured estimate of unbound testosterone (free or bioavailable)

Reimbursement context

Background and Clinical Context

Testosterone testing plays a role in the evaluation of suspected androgen deficiency or excess, monitoring response to therapy, and in diagnosis of certain conditions such as 5‑alpha reductase deficiency. The policy emphasizes that serum total testosterone is the primary screening test and that collection should occur in the early morning after fasting. Because total testosterone has considerable biological variability, the policy also notes the importance of using assays standardized to CDC HoSt/Testosterone where possible, and that measured or calculated free or bioavailable testosterone may be appropriate when total testosterone is low/borderline or SHBG abnormalities are suspected. Frequency recommendations include two measurements for initial male screening (≥24 hours apart) and specified monitoring intervals for testosterone replacement therapy (every 2–3 months for the first year after initiation or dose change, then annually).

Policy Revision History

2025-01-23literature_review_updateLatest

Document updated with literature review and references revised; reimbursement information unchanged; effective date listed as 04/15/2025.

2024-03-15literature_review_update

Document updated with literature review and references revised; reimbursement information unchanged.

2023-11-01operational_clarification

Added initial screening and follow-up screening language; specified that serum total testosterone samples should be collected early morning after fasting; noted assay sensitivity requirements for female serum total testosterone measurements.