CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLABOO9

Testosterone (Laboratory testing for testosterone and related sex-hormone assays)

Defines reimbursement criteria for serum total testosterone and related tests (free testosterone, SHBG, bioavailable testosterone, dihydrotestosterone, estradiol) — when testing is reimbursable versus not reimbursable for BCBS Oklahoma products. Affects providers ordering and billing laboratory hormone tests for members.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyTestosterone (Laboratory testing for testosterone and related sex-hormone assays)

Policy CodePolicy CPCPLABOO9

Change TypeClarifications and assay guidance

Effective DateNov 1, 2023

Next Review DateN/A

Key ActionCollect serum total testosterone in the early morning after fasting using a CDC HoSt/Testosterone-certified assay when possible and document the assay and specimen timing.

SourceLink

POLICY UPDATE CHANGES

Added initial screening and follow-up screening language for serum total testosterone.

Added Note 1 clarifying morning, fasting specimen collection and strong recommendation to use CDC HoSt/Testosterone‑certified assays.

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

Other reimbursement information revised for clarity and references updated.

1Policy number included

2Initial screening tests: two measurements ≥24 hours apart

60Days before allowable follow-up testing if initial screening normal but symptoms persist

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.

When Testing Is Reimbursable

Reimbursable (medically necessary) serum total testosterone

Measurement of serum total testosterone may be reimbursable in any of the following situations:

ANY of the following

Initial screening for symptoms of androgen deficiency or androgen excess in males
Two measurements at least 24 hours apart for initial screening
Follow-up testing when initial screening was normal but symptoms persist>= 60 days after initial screening
Monitoring men receiving testosterone replacement therapy
Every 2-3 months for the first year after initiation or dose change; annually thereafter
Monitoring treatment response in men taking enzyme inhibitors for prostate cancer
Testing for gender-dysphoric/gender-incongruent persons (baseline, during treatment, and for therapy monitoring)

Reimbursable additional/secondary assays

Measurement of additional assays may be reimbursable in the following situations:

ANY of the following

Annual measurement of serum free testosterone, SHBG, and/or albumin for males with total testosterone confirmed as low or borderline low AND who have hypogonadism, gynecomastia, and/or other forms of testicular hypofunction
Measurement of serum free testosterone (using validated algorithm based on total testosterone, SHBG, and/or albumin) or bioavailable testosterone for individuals suspected of having disorders with increased or decreased SHBG
Measurement of serum dihydrotestosterone for diagnosis of 5-alpha reductase deficiency in individuals with ambiguous genitalia, hypospadias, or microphallus
Once-per-lifetime serum estradiol measurement prior to initiating testosterone therapy for males with gynecomastia

Not reimbursable

The following uses are not reimbursable:

ANY of the following

Measurement of serum free testosterone and/or bioavailable testosterone as a primary test in the absence of prior serum total testosterone measurement
Measurement of serum total testosterone, free testosterone, and/or bioavailable testosterone for asymptomatic individuals or for individuals with non-specific symptoms
Measurement of serum testosterone for identification of androgen deficiency in women
Measurement of serum dihydrotestosterone for any situations not specifically mentioned as reimbursable

Specimen Timing and Monitoring Intervals

Key timing thresholds

Initial screening specimen timingTwo measurements at least 24 hours apart (total testosterone)

Follow-up testing intervalNo sooner than 60 days after initial screening if initial screening normal but symptoms persist

Monitoring interval for testosterone therapy (first year)Every 2-3 months after initiation or dose change

Monitoring interval for testosterone therapy (after first year)Annually

Documentation, Specimen Collection, and Denial Risks

Documentation Required

Specimen collection and assay selection

Collect serum total testosterone in the early morning after fasting. When possible, use an assay certified by the CDC HoSt/Testosterone program and document the specific assay used on the test order or in the medical record.

Early morning, fasting specimen collection required.
Prefer CDC HoSt/Testosterone-certified assay; list of certified assays available from CDC.
Document the assay method used when ordering/testing.

Documentation Required

Assay sensitivity for females

When ordering serum total testosterone in females, ensure the laboratory uses technology sensitive enough to detect the low serum total testosterone levels normally found in females and document this sensitivity when ordering or in the clinical record.

Confirm assay analytic sensitivity appropriate for female testosterone ranges before ordering.
Record or document the assay technology/sensitivity when testing females.

Clinical and Laboratory Context

BCBSOK defines clinical reimbursement conditions for serum testosterone and related hormone assays that align with guideline recommendations and recognize important analytic variability. The policy emphasizes that serum total testosterone levels vary considerably between assays and that laboratories and providers should, when possible, use assays certified by the CDC Hormone Standardization (HoSt)/Testosterone program. The policy also includes an operational recommendation that serum total testosterone sample collection occur in the early morning after fasting to reduce pre-analytical variability and that the assay used be documented when ordering and billing.

Because testosterone concentrations in females are normally low, the policy requires that laboratories use assay technology with sufficient analytic sensitivity when measuring serum total testosterone in females and that ordering providers document that the assay is appropriate for low female levels. The policy further notes the need for repeat testing in many clinical situations (for example, initial screening requires two measurements at least 24 hours apart and follow-up testing is allowed no sooner than 60 days after an initial normal screen if symptoms persist) and specifies monitoring intervals for therapy (for example, every 2–3 months during the first year after initiation or dose change, and annually thereafter for maintenance).

Policy language uses terms such as male and female to refer to sex assigned at birth for purposes of this coverage guidance. Providers are advised to review product-specific plan documents because reimbursement criteria in this policy may not apply uniformly across all BCBSOK products.

Defined Terms

Definitions

CDC HoSt/Testosterone programCenters for Disease Control and Prevention Hormone Standardization program for testosterone assay certification; recommended for assay standardization. Policy strongly recommends using an assay certified by the CDC HoSt/Testosterone program and notes early morning, fasting specimen collection.

Free testosterone / bioavailable testosterone measurementCalculated or measured estimates of the unbound fraction of testosterone; policy restricts primary use without prior total testosterone measurement and permits measurement in specified clinical situations (e.g., suspected SHBG disorders or confirmed low/borderline total testosterone with hypogonadism).

What Changed

2023-08-15added / materialLatest

New policy created and updated with literature review; added initial screening and follow-up screening language for serum total testosterone (two measurements ≥24 hours apart; follow-up allowed no sooner than 60 days if initial normal), added Note 1 specifying early-morning fasting specimen collection and recommendation to use CDC HoSt/Testosterone-certified assays, and added Note 2 regarding assay sensitivity for measuring low female testosterone levels.

2023-04-12approval

Policy version 1.0 approved (Approval Date: April 12, 2023; Plan Effective Date noted as November 1, 2023).

2023-11-01