CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB009

Testosterone

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.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyTestosterone

Policy CodePolicy CPCPLAB009

Change TypeNo material changes

Effective DateMay 1, 2026

Next Review Date

Key ActionOrder serum total testosterone as the initial test for suspected cases and document clinical indication and timing to support reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10numbered reimbursement items listed

1.0policy version

May 1, 2026plan effective date

CDC HoStassay certification recommended

Not reimbursablesaliva testing

Covered indications and related testing

Measurement of serum total testosterone may be reimbursable when ANY of the following situations apply:

Covered indications for serum total testosterone: a. Symptoms of androgen deficiency or androgen excess in males — initial screening requires two measurements at least 24 hours apart; if initial screening is normal but symptoms persist, follow-up testing allowed no sooner than 60 days after initial screening. b. Monitoring treatment response in men taking enzyme inhibitors for prostate cancer. c. Men receiving testosterone replacement therapy (every 2-3 months for the first year after initiation of therapy or after a change in therapeutic dosage; annually thereafter). 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., polycystic ovary syndrome and functional hypothalamic amenorrhea).

From reimbursement items 1a-1e

Additional reimbursable tests when indicated: 2. 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. 3. For individuals suspected of having a disorder accompanied by increased or decreased SHBG levels: 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. 4. Prior to initiating testosterone therapy for males with gynecomastia: once per lifetime serum estradiol measurement may be reimbursable. 5. For individuals with ambiguous genitalia, hypospadias, or microphallus: measurement of serum dihydrotestosterone for diagnosis of 5‑alpha reductase deficiency may be reimbursable.

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 male screening: Two separate serum total testosterone measurements obtained at least 24 hours apart.Two measurements

Initial screening requirement

Follow-up if initial normal but symptoms persist: Follow-up serum total testosterone testing is allowed no sooner than 60 days after the initial screening.No sooner than 60 days

Timing for repeat testing when symptoms persist

Exclusions for primary testing: Measurement of serum free and/or bioavailable testosterone as a primary test without a prior serum total testosterone measurement is not reimbursable.

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:

Testosterone replacement monitoring: For men receiving testosterone replacement therapy: testing 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 for first year; annually thereafter

Frequency limits for replacement therapy

Monitoring during enzyme inhibitor therapy: Monitoring of treatment response in men taking enzyme inhibitors for prostate cancer is reimbursable.

Monitoring indication

Documentation requirement: Providers must document clinical indication and timing (e.g., initiation date or dosage change) to support monitoring frequency.

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:

Symptomatic females evaluation: Serum total testosterone measurement for symptomatic females being evaluated for conditions associated with androgen excess (e.g., PCOS, functional hypothalamic amenorrhea).

Reimbursable only if clinically indicated

Assay sensitivity requirement: The assay technology must be sensitive enough to detect the low serum total testosterone levels normally found in females.

See Note 2 — use of appropriately sensitive assays required

Exclusion: Measurement of serum testosterone for identification of androgen deficiency in women is not reimbursable.

See exclusions

Disorders affecting SHBG — measurement of SHBG and free/bioavailable testosterone

Measurement may be reimbursable when ANY of the following apply:

Suspected SHBG-altering disorder: For individuals suspected of having a disorder accompanied by increased or decreased SHBG levels, 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.

Refer to Note 3 and Note 4 for conditions that alter SHBG

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

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 indication: For individuals with ambiguous genitalia, hypospadias, or microphallus: measurement of serum dihydrotestosterone for the diagnosis of 5‑alpha reductase deficiency may be reimbursable.

Diagnostic use only

Not reimbursable elsewhere: Measurement of serum dihydrotestosterone is not reimbursable for situations not specifically listed as reimbursable.

See reimbursement exclusions

Testing Frequency and Timing Rules

inv-22: serum total testosterone — Two (frequency descriptor)

FrequencyTwo serum total testosterone measurements (initial screening) at least 24 hours apart

When to collectSamples should be collected in the early morning, after fasting (see Note 1)

PurposeInitial screening for symptoms of androgen deficiency or androgen excess in males

inv-23: follow-up total testosterone when initial normal but symptoms persist — No sooner than 60 days

Minimum interval for follow-upNo sooner than 60 days after initial screening when initial total testosterone was normal but symptoms persist

Applies toMales with persistent symptoms of androgen deficiency or excess after a normal initial screen

DocumentationClinical documentation should support timing and persistent symptoms for follow-up testing

inv-24: monitoring serum testosterone during replacement therapy — Every 2-3 months then annually

Initial monitoring frequencyEvery 2-3 months during the first year after initiation of testosterone therapy or after a change in therapeutic dosage

Long-term monitoringAnnually thereafter

Also applies toMonitoring treatment response in men taking enzyme inhibitors for prostate cancer (per covered indications)

inv-25: serum estradiol — Once per lifetime

FrequencyOnce per lifetime prior to initiating testosterone therapy for males with gynecomastia

TestSerum estradiol measurement

PurposeBaseline evaluation before starting testosterone therapy in males with gynecomastia

inv-26: free testosterone, SHBG, and/or albumin for males with confirmed low/borderline total testosterone and hypogonadism/gynecomastia/testicular hypofunction — Annual

FrequencyAnnual measurements of serum free testosterone, SHBG, and/or albumin

IndicationMales with total testosterone confirmed as low or borderline low and who have hypogonadism, gynecomastia, or other testicular hypofunction

UseTo evaluate free or bioavailable testosterone and account for SHBG-related alterations

Provider Actions, Documentation, and Billing Requirements

Prior Authorization

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.

Step Therapy

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.

Documentation Required

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.

Denial Risk

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.

Denial Risk

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.

Revision History

2026-01-12policy_approvalLatest

Policy version 1.0 approved; document updated with literature review and references revised; plan effective date set to May 1, 2026.

2025-01-23literature_review_update

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

2024-03-15literature_review_update

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

2023-11-01content_revision

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.

2022-11-01policy_creation

New policy created.

OpenPayer

Testosterone

Coverage Criteria for Testosterone and Related Tests

Specific Clinical Indications Considered Reimbursable

Testing Frequency and Timing Rules

Procedure Codes and Coding Guidance

Provider Actions, Documentation, and Billing Requirements

Ordering and Documentation Requirements

Not Covered / Exclusions

Background and Assay Guidance

Definitions and Key Concepts

Revision History