CurrentFidelis CarePolicy FC.CG.PP.15

Endocrinology Non-Genetic Testing

Defines medical necessity coverage and noncoverage criteria for a range of non-genetic endocrine laboratory tests (thyroid, sex hormones, AMH, estradiol, FSH, LH, prolactin, progesterone, general health panel, HbA1c, PTH, etc.) for Fidelis Care Medicaid and Health Insurance Marketplace products.

Policy Summary

PayerFidelis Care

PolicyEndocrinology Non-Genetic Testing

Policy CodePolicy FC.CG.PP.15

Change TypePolicy developed (02/2026)

Effective Date

Next Review Date

Key ActionProviders must document signs/symptoms, risk factors, monitoring reason, abnormal prior results, or pregnancy/infertility/therapy status as applicable to meet the specific coverage criteria for each test.

SourceLink

POLICY UPDATE CHANGES

Policy developed.

MultipleEndocrine tests covered conditionally

1Revision entries

48+References cited (partial)

Coverage Summary

Scope: This policy defines medical necessity coverage and noncoverage criteria for a range of non‑genetic endocrine laboratory tests (thyroid function tests, sex hormones including testosterone and estradiol, AMH, FSH, LH, prolactin, progesterone, general health panel, HbA1c, PTH, and related endocrine panels) for Fidelis Care products, specifically Medicaid and Health Insurance Marketplace plans. It establishes which indications, monitoring scenarios, reflex testing, and exclusions meet the covered_with_criteria stance for these tests.

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Overview: Fidelis Care covers endocrine non‑genetic laboratory testing with criteria — tests are covered when specified clinical indications, risk factors, monitoring needs, or abnormal prior results are documented; many tests are not covered when ordered for asymptomatic screening or without qualifying reasons. The policy applies to the listed endocrine tests and CPT panels and includes guidance on reflex testing, documentation requirements, and precedence of state Medicaid or Medicare determinations where applicable.

Policy metadata & thresholds

policy_numberFC.CG.PP.15

statusCURRENT

last_review2026-02-26

policy_development_date02/2026

scope_summaryDefines medical necessity coverage and noncoverage criteria for a range of non-genetic endocrine laboratory tests (thyroid, sex hormones, AMH, estradiol, FSH, LH, prolactin, progesterone, general health panel, HbA1c, PTH, etc.) for Fidelis Care Medicaid and Health Insurance Marketplace products.

thresholdsFasting morning total testosterone for male infertility evaluation: <300 ng/dL; HbA1c monitoring interval - pregnancy with diabetes/GDM: >= 30 days since last test; HbA1c monitoring interval - diabetes/prediabetes/high-risk meds: >= 90 days since last test; HbA1c monitoring interval - certain risk groups: >= 1 year since last test.

Medical Necessity Criteria (by test)

Thyroid Stimulating Hormone (TSH) Testing

TSH testing is covered when ANY of the following are met:

ANY of the following

Member/enrollee has signs or symptoms of thyroid dysfunction.
Member/enrollee has one or more increased risk factors associated with thyroid dysfunction.
Member/enrollee is being monitored during treatment for thyroid dysfunction.
Member/enrollee is being monitored during treatment of thyroid carcinoma including post thyroidectomy, radiation, and suppression.

Not covered: TSH testing is not covered for all other indications, including screening of asymptomatic adults without increased risk factors for thyroid dysfunction.

Free Thyroxine (T4) / Total T4 / Free Thyroxine Index

Coverage when ANY of the following are met; additional specific noncoverage rules apply:

ANY of the following

Member/enrollee has an abnormal TSH result.
Member/enrollee has signs or symptoms of thyroid dysfunction.
Member/enrollee is being monitored during treatment for thyroid dysfunction.

Use of measurement of T3 uptake is not covered when performed without total T4.

Use of free thyroxine index (total T4 and T3 uptake) is not covered when performed simultaneously with free T4.

Total Triiodothyronine (T3) Testing

Total T3 testing is covered when ANY of the following are met:

ANY of the following

Member/enrollee has an abnormal TSH result.
Member/enrollee has signs or symptoms of hyperthyroidism.
Member/enrollee is being monitored during treatment for hyperthyroidism.

Total T3 testing is not covered for all other indications, including screening of asymptomatic adults without increased risk factors for thyroid dysfunction.

Footnote: Total T3 reflex from initial TSH is considered appropriate for initial thyroid dysfunction testing.

Free Triiodothyronine (Free T3) Testing

Free T3 testing is covered when ALL of the following are met:

ALL of the following

Member/enrollee is receiving combined T3/T4 (liothyronine/levothyroxine) therapy.
Member/enrollee has a low or suppressed TSH level suggestive of possible overreplacement.

Free T3 testing is not covered for all other indications, including screening of asymptomatic member/enrollees without increased risk factors for thyroid dysfunction.

Reverse T3 Testing

Reverse T3 testing coverage stance:

Use of reverse triiodothyronine (rT3) testing is not covered for all indications, including screening of asymptomatic member/enrollees without increased risk factors for thyroid dysfunction.

Testosterone Testing (total, free, bioavailable)

Testosterone testing is covered when ANY of the following are met; additional rules for simultaneous total+free:

ANY of the following

Member/enrollee is being monitored during testosterone therapy, antiandrogen/androgen deprivation therapy, or treatment with a gonadotropin-releasing hormone (GnRH) agonist.
Member/enrollee has irregular menstrual cycles.
Member/enrollee has clinical signs of hyperandrogenism (e.g., hirsutism, severe acne, female pattern hair loss).
Male-specific indications: Member/enrollee is male AND has one or more of: sexual/erectile dysfunction; infertility due to oligo- or azoospermia; signs or symptoms of male hypogonadism; personal history of conditions associated with increased risk for testosterone deficiency; signs of precocious puberty; signs of delayed puberty.

Anti-Mullerian Hormone (AMH) Testing

AMH testing is covered when ANY of the following are met:

ANY of the following

Member/enrollee is an adult being evaluated for ovarian stimulation/in vitro fertilization (IVF).
Member/enrollee is an adult being evaluated for polycystic ovarian syndrome (PCOS) AND AMH is being used as an alternative to ultrasound to confirm polycystic ovary morphology (PCOM).
Member/enrollee has signs of a disorder of sexual development (e.g., ambiguous genitalia, cryptorchidism, hypospadias).

AMH testing is not covered for all other indications.

Note: AMH testing is not recommended for evaluation of adolescents for PCOS due to poor specificity.

Estradiol Testing

Estradiol testing is covered when ANY of the following are met:

ANY of the following

Member/enrollee has irregular menstruation prior to 40 years of age.
Testing is required to make a definitive clinical diagnosis of menopause due to inadequate menstrual history or hysterectomy without bilateral oophorectomy.
Member/enrollee is being monitored during estrogen therapy and/or antiandrogen/androgen deprivation therapy.
Member/enrollee is being monitored during endocrine therapy for premenopausal hormone receptor positive breast cancer (ovarian function suppression).
Member/enrollee has gynecomastia that cannot be attributed to hepatic, renal or thyroid dysfunction.

Follicle Stimulating Hormone (FSH) Testing

FSH testing is covered when ANY of the following are met:

ANY of the following

Testing is required to make a definitive clinical diagnosis of menopause due to inadequate menstrual history or hysterectomy without bilateral oophorectomy.
Member/enrollee is being monitored during endocrine therapy for premenopausal hormone receptor positive breast cancer (ovarian function suppression).
Member/enrollee is being monitored during treatment with a gonadotropin-releasing hormone (GnRH) agonist.
Member/enrollee has gynecomastia not explained by hepatic, renal or thyroid dysfunction.
Signs/conditions:

Luteinizing Hormone (LH) Testing

LH testing is covered when ANY of the following are met:

ANY of the following

Member/enrollee has signs or symptoms of male or female hypogonadism.
Member/enrollee has gynecomastia not explained by hepatic, renal or thyroid dysfunction.
Member/enrollee has signs of precocious puberty.
Member/enrollee is being monitored during endocrine therapy for premenopausal hormone receptor positive breast cancer (ovarian function suppression).
Member/enrollee is being monitored during treatment with a gonadotropin-releasing hormone (GnRH) agonist.

Prolactin Testing

Prolactin testing is covered when ANY of the following are met:

Clinical findings: Signs/symptoms of PCOS; Signs/symptoms of male or female hypogonadism; Gynecomastia not explained by hepatic, renal or thyroid dysfunction; Galactorrhea; Low bone mass; Symptoms of a pituitary mass (e.g., double vision/decreased peripheral vision, frequent/severe/prolonged headaches); A pituitary neoplasm detected on brain imaging.

Female infertility: Member/enrollee has female factor infertility AND irregular menstruation (oligomenorrhea or amenorrhea) and/or anovulation.

Male infertility: Member/enrollee has male factor infertility AND a fasting morning total testosterone level below <300 ng/dL.<300 ng/dL

Member/enrollee is being evaluated for or monitored during treatment of a prolactinoma/hyperprolactinemia or for hypopituitarism.

Progesterone Testing

Progesterone testing is covered when ANY of the following are met:

First-trimester bleeding: Member/enrollee has first-trimester bleeding AND ultrasound-confirmed intrauterine pregnancy AND inconclusive pregnancy viability.

Member/enrollee is being evaluated for embryo transfer.

Member/enrollee has regular menstruation AND (clinical signs of hyperandrogenism OR female factor infertility).

Progesterone testing is not covered for all other indications.

General Health Panel (CMP + TSH + CBC)

General health panel testing is covered when ALL of the following are met:

Member/enrollee meets criteria for Thyroid Stimulating Hormone (TSH) testing.

General health panel is not covered for all other indications.

Note: 'General Health Panel' is an order set billed with a single procedure code that includes CMP, TSH, and CBC.

Hemoglobin A1C (HbA1c) Testing

HbA1c testing is covered when ANY of the following criteria sets are met:

Pregnancy with diabetes/GDM: Member/enrollee is pregnant AND has diabetes mellitus or gestational diabetes mellitus (GDM) AND it has been at least 30 days since the member/enrollee's last test.>= 30 days since last test

Diabetes/prediabetes/high-risk meds: Member/enrollee has one of: diabetes mellitus OR prediabetes OR use of high-risk medications (e.g., statins, second-generation antipsychotic, glucocorticoids) AND it has been at least 90 days since the member/enrollee's last test.>= 90 days since last test

Signs/symptoms of insulin resistance or diabetes OR overweight/obesity with risk factor: Member/enrollee has signs/symptoms of insulin resistance or diabetes OR has overweight or obesity AND one or more additional risk factors for diabetes OR personal history of gestational diabetes OR personal history of pancreatitis, AND it has been at least one year since the member/enrollee's last test.

Parathyroid Hormone (PTH) Testing

PTH testing is covered when ANY of the following are met:

Member/enrollee has signs or symptoms of parathyroid dysfunction; Member/enrollee has risk factors for parathyroid dysfunction; Member/enrollee is being monitored during and/or after treatment for parathyroid dysfunction/cancer (e.g., medication, dietary control, surgery); There is clinical suspicion or diagnosis of cancer known to affect the parathyroid or cause signs of parathyroid dysfunction (e.g., MEN2A/Familial medullary thyroid carcinoma, multiple endocrine neoplasia types 1 and 2, brown tumor of hyperparathyroidism).

PTH testing is not covered for all other indications, including screening of asymptomatic individuals with no additional risk factors or clinical findings.

Not Covered / Experimental

Noncovered and restricted uses (aggregate)

Aggregate noncovered statements from the policy (tests or uses explicitly stated as not covered):

Reverse T3: Use of reverse triiodothyronine (rT3) testing is not covered for all indications, including screening of asymptomatic member/enrollees without increased risk factors for thyroid dysfunction.

T3 uptake without total T4: Measurement of T3 uptake is not covered when performed without total T4.

Free thyroxine index simultaneous with free T4: Free thyroxine index (total T4 and T3 uptake) is not covered when performed simultaneously with free T4.

Total/Free T3 and Free T4 general noncoverage: Total T3 testing, Free T3 testing, and Free T4/Total T4/Free Thyroxine Index testing are not covered for all other indications, including screening of asymptomatic adults without increased risk factors for thyroid dysfunction, except where explicit reflex/monitoring exceptions are stated.

Testosterone simultaneous total+free not covered: Measuring both total and free testosterone simultaneously is not covered for all other indications except when evaluating PCOS or when signs of hypogonadism with a factor altering SHBG are present; testosterone testing is not covered for routine evaluation of age-related low testosterone in adult men.

AMH noncoverage: AMH testing is not covered for all other indications and is not recommended for evaluation of adolescents for PCOS due to poor specificity.

General Health Panel single code: General Health Panel order sets are billed with a single procedure code (80050) and general health panel testing is not covered for all other indications unless TSH criteria are met.

Coding

Referenced CPT / Panel Codes (informational)CPT

80050	General health panel (CMP + TSH + CBC) - must include listed components
80061	Lipid panel
80377	Drug/substance definitive qual/quant NOS 7/more
80400	ACTH stimulation panel adrenal insufficiency
80402	ACTH stimulation panel 21 hydroxylase deficiency
80408	Aldosterone suppression evaluation panel
80410	Calcitonin stimulation panel
80412	Corticotropic releasing hormone stimulation panel
80414	Chorionic gonadotropin stimulation panel; testosterone response
80415	Chorionic gonadotropin stimulation panel; estradiol response

1–10 of 108

1/11

Provider Actions & Billing Rules

Documentation Required

Support medical necessity in chart

Providers must document signs/symptoms, risk factors, monitoring reason, abnormal prior results, or pregnancy/infertility/therapy status as applicable to meet the specific coverage criteria for each test.

Billing Rule

General health panel single code billing

General Health Panel is an order set billed with a single procedure code (80050) that must include CMP, TSH, and CBC components.

80050 — General health panel (single-panel code including CMP, TSH, and CBC)

Billing Rule

Reflex testing allowed

Reflex free T4 or total T3 testing from an abnormal initial TSH is considered appropriate for initial thyroid dysfunction testing; documentation of the reflex rationale is required.

84439 — Thyroxine; free (free T4)
84480 — Triiodothyronine T3; total (total T3)
Reflex testing (automatic free T4 or total T3) is appropriate following an abnormal initial TSH and should be documented

Documentation Required

Follow plan terms and state/federal requirements

Providers must adhere to all terms, conditions, exclusions and limitations of the member's coverage documents and applicable state and federal requirements when submitting claims and seeking payment under this policy.

Documentation Required

Medicaid precedence

For Medicaid members/enrollees, state Medicaid coverage provisions take precedence if they conflict with this payment policy; refer to the state Medicaid manual for coverage provisions.

Documentation Required

Review NCDs and LCDs for Medicare

For Medicare members/enrollees, providers should review applicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) prior to applying criteria in this payment policy.

Billing Rule

Policy adoption and effective date governance

This payment policy is effective as of the date determined by Fidelis Care; the posting date may not equal the effective date and applicable legal/regulatory notification requirements govern in case of discrepancy.

Documentation Required

Provider independence and responsibility

Providers are independent contractors responsible for medical judgment, treatment decisions, and documentation; the policy does not constitute medical advice or guarantee payment.

Background

The endocrine system controls hormones that regulate sexual development, reproduction, growth, respiration and metabolism; hormonal imbalances can cause conditions such as thyroid disease, infertility, abnormal growth, Cushing's syndrome, polycystic ovary syndrome, erectile dysfunction, and symptoms related to age‑associated changes (e.g., menopause, low testosterone), and identifying these imbalances via laboratory testing can guide selection of surgery, medication, or hormone replacement therapy.

Laboratory endocrine testing is indicated in clinical contexts to identify whether an underlying hormone imbalance explains presenting problems (for example thyroid dysfunction, infertility, disorders of sexual development, adrenal or parathyroid disease) and to monitor treatment; the policy uses the terms male and female where necessary based on published guidelines.

This policy was developed in 02/2026 (revision history: Policy developed) and cites a broad evidence base including guideline sources (e.g., USPSTF, ACOG, ATA, Endocrine Society, ADA, NCCN) with 48+ references cited.

Definitions (quick reference)

Conditions associated with increased risk for testosterone deficiencyInclude unexplained anemia, bone density loss/unexplained fracture, diabetes, exposure to chemotherapy, direct or scatter radiation therapy to the testes, HIV.

Factors known to alter SHBG levelsInclude aging, obesity, diabetes mellitus, use of glucocorticoids, progestins, androgenic steroids, estrogens, nephrotic syndrome, cirrhosis/hepatitis, hypo/hyperthyroidism, acromegaly, HIV disease, certain anticonvulsants, and SHBG gene polymorphisms.

Increased risk factors associated with thyroid dysfunctionMay include autoimmune diseases, heart disease, Down syndrome, Turner syndrome, Addison disease, prior thyroid surgery, radioiodine treatment, neck radiation, and certain medications (amiodarone, lithium, interferons, rifampin, tyrosine kinase inhibitors, phenobarbital, interleukin-2, immune checkpoint inhibitors), and family history.

Health Plan definitionA health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any affiliate, as applicable.

Revision History

2026-02added

Policy developed. Revision history indicates policy developed 02/2026.

2026-02-26addedLatest

Policy developed. Revision history notes policy developed 02/2026. (Material change)

Policy Summary

PayerFidelis Care

PolicyEndocrinology Non-Genetic Testing

Policy CodePolicy FC.CG.PP.15

Change TypePolicy developed (02/2026)

Effective Date

Next Review Date

SourceLink

On This Page

Free T4/total T4/free thyroxine index testing is not covered for all other indications, including screening of asymptomatic adults without increased risk factors for thyroid dysfunction.

Footnote: Reflex (automatic) free T4 from an initial TSH is considered appropriate for initial thyroid dysfunction testing.

Measuring both total and free testosterone simultaneously is covered when: Member/enrollee is being evaluated for irregular menstrual cycles and/or hyperandrogenism for PCOS OR member/enrollee has signs/symptoms of hypogonadism AND a factor known to alter SHBG levels.

Measuring both total and free testosterone simultaneously is not covered for all other indications. Testosterone testing is not covered for all other indications, including routine evaluation of age-related low testosterone in adult men.

Member/enrollee has female factor infertility AND irregular menstruation (oligomenorrhea or amenorrhea) and/or anovulation.

Member/enrollee has a female reproductive system AND (signs/symptoms of female hypogonadism, delayed puberty, and/or primary amenorrhea) OR (signs of precocious puberty).

Estradiol testing is not covered for all other indications.

Signs/symptoms of PCOS (e.g., irregular menstrual cycles, clinical or biochemical hyperandrogenism); Irregular menstruation prior to 40 years of age; Signs or symptoms of male hypogonadism.

Male factor infertility: Member/enrollee has male factor infertility AND one of: sexual/erectile dysfunction; oligo/azoospermia; atrophic testes; evidence of hormonal abnormality on exam (e.g., gynecomastia, abnormally sized testes).

Female factor infertility: Member/enrollee has female factor infertility AND irregular menstruation (oligomenorrhea or amenorrhea) and/or anovulation.

Member/enrollee has a pituitary neoplasm detected on brain imaging.

FSH testing is not covered for all other indications.

Member/enrollee has a pituitary neoplasm detected on brain imaging.

LH testing is not covered for all other indications.

Member/enrollee is being monitored during estrogen therapy and/or antiandrogen/androgen deprivation therapy.

Prolactin testing is not covered for all other indications.

>= 1 year since last test

The use of Hemoglobin A1C (HbA1c) testing is not covered [text truncated in source].