CurrentEmblemHealthPolicy AHS-G2013

Testosterone - Lab Benefit Program (LBM)

Defines coverage criteria and limitations for laboratory measurement of testosterone and related analytes for EmblemHealth plans, including indications for testing, recommended assays, and situations that do not meet coverage.

Policy Summary

PayerEmblemHealth

PolicyTestosterone - Lab Benefit Program (LBM)

Policy CodePolicy AHS-G2013

Change TypeCoverage expansioncontent reorganizationclarifications

Effective DateMar 1, 2023

Next Review DateN/A

Key ActionFollow billing and claims payment policies and coding edits; claims may be denied or recouped if guidelines are not followed.

SourceLink

POLICY UPDATE CHANGES

Lab Benefit Program (LBM) expanded to include EmblemHealth HMO/ PPO (Non-City) Commercial, Medicare and Medicaid plans effective 10/1/2024.

Updated policy title from 'Testosterone Testing' to 'Testosterone' and reorganized coverage criteria (splitting and moving technical specifics).

Updated for clarity; no changes to coding or coverage criteria.

Transferred policy content to individual company-branded template.

2initial morning TT measurements

60follow-up wait (days)

2–3 momonitoring frequency (first year)

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.

<300 ng/dLAUA diagnostic cutoff

10+procedure codes listed

Coverage Criteria for Testosterone Testing

Applicable Codes and Coding Notes

Applicable coding edits and referencesmixed

No codes listed

Testosterone LBM coding (not specified in this segment)mixed

No codes listed

Applicable CPT/HCPCS codesCPT

82040	Albumin; serum, plasma or whole blood
82642	Dihydrotestosterone (DHT)
82670	Estradiol; total
82681	Estradiol; free, direct measurement (eg, equilibrium dialysis)
84270	Sex hormone binding globulin (SHBG)
84402	Testosterone; free
84403	Testosterone; total
84410	Testosterone; bioavailable, direct measurement (eg, differential precipitation)

Applicable CPT/HCPCS Procedure CodesCPTCovered

82040	Albumin; serum, plasma or whole blood
82642	Dihydrotestosterone (DHT)
82670	Estradiol; total
82681	Estradiol; free, direct measurement (eg, equilibrium dialysis)
84270	Sex hormone binding globulin (SHBG)
84402	Testosterone; free
84403	Testosterone; total
84410	Testosterone; bioavailable, direct measurement (eg, differential precipitation)

CDC HoSt acceptance limit — key values

CDC HoSt acceptance limit±6.4% acceptance limit for comparison to assigned reference values (calibration verified every six months)

Reportable range (ID-LC-MS/MS)2.5–1000 ng/dL (0.09–34.7 nM) with LOD 0.36 ng/dL

Precision (%CV) reported by CDCPrecision ranges from 2.2% to 5.5% for total serum testosterone

AUA total testosterone diagnostic cutoff — key values

AUA diagnostic cutoffTotal testosterone < 300 ng/dL as a reasonable cut-off to support diagnosis of low testosterone

Confirmatory testingDiagnosis should be made only after two total testosterone measurements on separate early-morning occasions

Clinical correlationLow total testosterone must be combined with symptoms/signs to establish diagnosis

Provider Billing, Claims, and Operational Guidance

Documentation Required

Billing, Claims, Documentation, and Enforcement

Providers must follow EmblemHealth billing and claims payment policies, coding guidelines, and documentation requirements. Claims that do not adhere to applicable coding/billing guidelines, Reimbursement Policy requirements, or the member's benefit coverage documents may be denied or subject to recoupment. EmblemHealth follows industry coding edits (including CPT, CMS/NCCI/MUE) and uses claims‑editing software; when conflicts exist between sources, EmblemHealth will apply the edits it determines appropriate. Upon request, EmblemHealth will provide an explanation of how specific coding issues are handled.

Providers should maintain documentation supporting medical necessity and diagnostic testing for testosterone-related assays and retain records per contract and regulatory requirements.
Failure to follow coding/billing guidelines or this Reimbursement Policy may result in claim denial and/or recoupment.
EmblemHealth posts policy updates on the Reimbursement Policies webpages, provider manual, and provider newsletters — providers are responsible for monitoring these sources for changes.

Key Terms and Abbreviations

Key terms and abbreviations

HoStHormone standardization (CDC HoSt) program for assay certification and calibration

TTTotal testosterone

SHBGSex hormone binding globulin

FTFree testosterone

DHTDihydrotestosterone

Equilibrium dialysis — definition & technical notes

DefinitionEquilibrium dialysis: the gold-standard method to determine free serum testosterone using a semipermeable membrane to separate bound and free fractions

Policy Summary

PayerEmblemHealth

PolicyTestosterone - Lab Benefit Program (LBM)

Policy CodePolicy AHS-G2013

Change TypeCoverage expansioncontent reorganizationclarifications

Effective DateMar 1, 2023

Next Review DateN/A

Key ActionFollow billing and claims payment policies and coding edits; claims may be denied or recouped if guidelines are not followed.

SourceLink

On This Page

Billing Rule

Procedure Codes and Coding Guidance

Applicable procedure codes for testosterone and related hormone assays are provided for billing reference. Procedure codes listed in policy documents are for reference and may not be all-inclusive. Confirm member benefit coverage and any applicable prior authorization requirements before billing.

Technical considerationsTechnically difficult, limited availability, and relatively expensive; relies on accurate total testosterone measurement

Environmental effectsResults depend on pH, ionic strength, and temperature (binding can vary substantially with temperature)

Direct analog-based free testosterone immunoassay — definition & recommendation

DefinitionDirect analog-based free testosterone immunoassays: immunoassay methods that directly measure free testosterone using analog techniques

Society recommendationThe Endocrine Society specifically advises clinicians not to use direct analog–based free testosterone immunoassays due to inaccuracy

Alternative approachesUse accepted algorithms based on TT, SHBG, and albumin or equilibrium dialysis methods instead

LDT — definition & regulatory note (CLIA '88)

DefinitionLaboratory-developed tests (LDTs): tests developed and validated in-house by laboratories

Regulatory noteLDTs are regulated by CMS as high-complexity tests under CLIA '88 and are not FDA-approved/cleared; FDA clearance is not currently required for clinical use

Clinical implicationLabs must validate LDTs for clinical use per CLIA '88 requirements

Morning total testosterone — timing & sample considerations

DefinitionMorning total testosterone: total serum testosterone measured on fasting morning blood samples (typically before 11:00)

Timing recommendationMeasure in early morning (commonly between 07:00 and 11:00) and obtain samples on two separate days when diagnosing hypogonadism

Fasting noteFasting morning samples are recommended as concentrations can vary with circadian and other factors

Applicable CPT/HCPCS Procedure Codes — listing

82040Albumin; serum, plasma or whole blood

82642Dihydrotestosterone (DHT)

82670Estradiol; total

82681Estradiol; free, direct measurement (eg, equilibrium dialysis)

84270Sex hormone binding globulin (SHBG)

84402Testosterone; free

84403Testosterone; total

84410Testosterone; bioavailable, direct measurement (eg, differential precipitation)