Testosterone
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Laboratory coverage and reimbursement criteria for serum testosterone and related hormone tests for Blue Cross Blue Shield - Oklahoma members; governs when tests are reimbursable and when they are not, and provides testing/assay guidance for providers.
No material clinical or coverage changes in this revision.
Coverage Criteria for Testosterone and Related Tests
Covered indications and related testing
Measurement of serum total testosterone may be reimbursable when ANY of the following situations apply:
From reimbursement items 1a-1e
From reimbursement items 2-5
Measurement of serum free testosterone and/or bioavailable testosterone as a primary test (that is, performed without a prior serum total testosterone measurement) is not reimbursable.
Testing for serum total, free, or bioavailable testosterone in asymptomatic individuals or for non‑specific symptoms is not reimbursable and is considered not medically necessary.
Measurement of serum testosterone for the purpose of identifying androgen deficiency in women is not reimbursable.
The use of saliva specimens for measurement of testosterone is not reimbursable and claims for saliva testing will be denied.
Measurement of serum dihydrotestosterone is not reimbursable for indications other than those specifically listed as reimbursable in the policy.
Tests ordered for asymptomatic individuals or for non‑specific symptoms are considered not medically necessary and will not be reimbursed.
Specific Clinical Indications Considered Reimbursable
Symptoms of androgen deficiency/excess in males — initial screening rules
Covered when ALL of the following are met:
Initial screening requirement
Timing for repeat testing when symptoms persist
See reimbursement exclusions
Monitoring therapy — frequency and conditions for men on testosterone replacement or enzyme inhibitors
Monitoring covered when ALL of the following timing rules are met:
Frequency limits for replacement therapy
Monitoring indication
Claims may be subject to review per policy
Evaluation of androgen excess in symptomatic females — assay sensitivity
Covered when ALL of the following are true:
Reimbursable only if clinically indicated
See Note 2 — use of appropriately sensitive assays required
See exclusions
Disorders affecting SHBG — measurement of SHBG and free/bioavailable testosterone
Measurement may be reimbursable when ANY of the following apply:
Refer to Note 3 and Note 4 for conditions that alter SHBG
Frequency limit for confirmatory testing
Ambiguous genitalia or suspected 5-alpha reductase deficiency — serum dihydrotestosterone
Measurement may be reimbursable when ANY of the following clinical criteria are met:
Diagnostic use only
See reimbursement exclusions
Testing Frequency and Timing Rules
Procedure Codes and Coding Guidance
| No codes listed |
Provider Actions, Documentation, and Billing Requirements
Prior authorization — None specified; coverage tied to indications
No explicit prior authorization requirement is stated in this policy; reimbursement is determined by whether the test meets the listed clinical indications and timing requirements.
Testing sequence — Total testosterone first; free/bioavailable for follow-up
Measure serum total testosterone as the initial test for suspected cases; reserve measurement of serum free or bioavailable testosterone for confirmatory evaluation when total testosterone is low/borderline or when disorders affecting SHBG are suspected.
Clinical documentation and timing — Support indication and timing
Providers must submit accurate documentation that supports the clinical indication for testing and the timing of specimen collection and repeat testing per the policy (e.g., two total testosterone measurements ≥24 hours apart for initial male screening; follow-up testing no sooner than 60 days when initial screening is normal). Claims must use valid code combinations.
Saliva testing excluded — Not reimbursable
The use of saliva for measurement of testosterone is not reimbursable; claims for saliva-based testosterone testing will be denied.
Primary free/bioavailable testing without prior total — Not reimbursable
Measurement of serum free and/or bioavailable testosterone as a primary test without a prior serum total testosterone measurement is not reimbursable and may be denied.
Ordering and Documentation Requirements
ORDERING REQUIREMENTS — Order per indications; document timing and reason; code claims correctly
Order tests that are consistent with the policy's reimbursable clinical indications, document the clinical reason and specimen timing, and submit claims using standard, valid coding; claims may be subject to review.
- Document clinical indication (e.g., symptoms, monitoring therapy, suspected SHBG disorder).
- Document timing per frequency limits (e.g., two initial total testosterone measurements ≥24 hours apart; follow-up ≥60 days if indicated).
- Use valid code combinations from standard code sets when submitting claims.
Not Covered / Exclusions
The use of saliva for measurement of testosterone is explicitly listed as not covered and is not reimbursable.
Ordering serum free and/or bioavailable testosterone as the initial or primary assay without first obtaining a serum total testosterone measurement is not covered.
Measurement of testosterone for the identification of androgen deficiency in women is not covered.
Measurement of serum dihydrotestosterone for indications that are not specifically listed among the reimbursable situations is not covered.
Background and Assay Guidance
Serum total testosterone exhibits considerable biological variability. Collect specimens in the early morning after fasting when possible. Because of assay variability, the policy strongly recommends using an assay certified by the CDC HoSt/Testosterone program; CDC‑certified assays are standardized to within ±6.4% of the CDC reference standard and a certified‑assay list is available on the HoSt website. When measuring total testosterone in females, use technology with sufficient sensitivity to detect the low levels normally present in females.
Definitions and Key Concepts
Revision History
Policy version 1.0 approved; document updated with literature review and references revised; plan effective date set to May 1, 2026.
Document updated with literature review and references revised; reimbursement information unchanged.
Document updated with literature review and references revised; reimbursement information unchanged.
Document updated with literature review; added initial screening and follow-up screening language to reimbursement item 1a and added Note 1 (collection timing) and Note 2 (assay sensitivity for females); other reimbursement information revised and references updated.
New policy created.
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