CurrentHighmark Blueshield NenyPolicy N/A

Testosterone therapy prior authorization form - Coverage Criteria

This document governs prior authorization requirements and clinical information collection for testosterone therapies (including treatment and reauthorization) for Highmark BlueShield members; it affects prescribing providers seeking coverage for testosterone products.

Policy Summary

PayerHighmark Blueshield Neny

PolicyTestosterone therapy prior authorization form - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a separate completed form and all clinical documentation by fax or mail to obtain prior authorization for each testosterone medication request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2required pre-treatment morning testosterone measurements

12+examples of causes of primary hypogonadism listed

30/90/otherrequested supply day options

recent levelreauthorization requirement

Coverage Criteria for Testosterone Therapy

Initial authorization criteria

Covered when ALL of the following are met:

Diagnostic confirmation

Indications list: Primary hypogonadism OR secondary hypogonadism due to hypopituitarism OR delayed puberty OR metastatic breast cancer for palliative treatment OR gender dysphoria-related therapy
For primary hypogonadism, causes listed include double orchidectomy, cryptorchidism, bilateral torsions, orchitis, vanishing testis syndrome, single orchidectomy, Klinefelter's syndrome, chemotherapy/radiation/toxic/surgical damage
Laboratory confirmation: Documentation of two morning (before 11:00 AM) pre-treatment total testosterone levels AND two morning (before 11:00 AM) pre-treatment free testosterone levels with dates and times2 morning total and 2 morning free testosterone measurements
Provide lab reports for verification

Policy Summary

PayerHighmark Blueshield Neny

PolicyTestosterone therapy prior authorization form - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a separate completed form and all clinical documentation by fax or mail to obtain prior authorization for each testosterone medication request.

SourceLink

On This Page

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The form does not list explicit exclusions as standalone NMN items. Instead, it includes screening questions to identify clinical contexts that may affect appropriateness of therapy—for example it asks whether testosterone is being considered for a member on chronic steroid treatment or for weight loss due to HIV infection. These screening items should be used to inform medical review but are not presented on the form as categorical exclusions.

Because the form relies on provider responses to targeted questions rather than a separate exclusion list, reviewers should verify answers and supporting documentation when these conditions are present to determine whether treatment is clinically appropriate for the individual member.

The form requires objective diagnostic confirmation: providers must supply two morning (before 11:00 AM) pre‑treatment total and free testosterone results with reference ranges, dates, and times. It also requires documentation of symptoms or signs consistent with low testosterone (for example reduced libido, hot flushes/sweats, loss of axillary/pubic hair, small testes, delayed sexual development, low sperm count, low bone mineral density, or gynecomastia).

Note that the form does not explicitly label any conditions as not medically necessary; rather, it uses laboratory confirmation and symptom documentation to support medical necessity. Also, the form’s gender dysphoria section asks diagnostic and competency questions (e.g., prescriber competence for patients ≤15 years) but does not explicitly require separate NMN language for those indications.

Required Diagnostic Measurements

inv-05: Pre-treatment testosterone measurements — 2 morning (before 11:00 AM) total and free testosterone levels

Required pre-treatment measurementsTwo morning (before 11:00 AM) total testosterone levels and two morning (before 11:00 AM) free testosterone levels documented with reference ranges, dates, and times

Timing requirementSpecimens must be collected in the morning (before 11:00 AM)

Documentation detailsProvide lab results with reference ranges, date collected, and time collected for each total and free testosterone measurement

Exception for no endogenous productionIf the member is not producing any testosterone, check the corresponding box on the form

Unavailable records attestationIf pre-treatment medical records are unavailable, the provider may attest to that fact on the form

Actions Required of Ordering Providers

Prior Authorization

Prior authorization form submission

Submit a separate completed prior authorization form and all required clinical documentation (labs, medication history, etc.) by fax or mail for EACH testosterone medication requested. Fax: 1-866-240-8123. Mail: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222.

Submit a separate form and documentation for each medication
Fax: 1-866-240-8123
Mail: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222

Documentation Required

Prior medication history

Provide prior medication history including any other testosterone therapies or relevant medications the member has tried and failed. Include dates, dosages, and reasons for discontinuation when available.

List other testosterone therapies tried and failed
Include dates, dosages, and reasons for discontinuation

Documentation Required

Documentation for labs

Provide documentation of two morning (before 11:00 AM) pre-treatment Total and Free Testosterone lab results with dates and times collected. For reauthorization requests, provide a testosterone level within the past 12 months with documentation of lab results.

Two morning (before 11:00 AM) pre-treatment Total and Free Testosterone results with dates/times
For reauthorization: testosterone level within past 12 months with documentation

Denial Risk

Incomplete or inaccurate information may lead to payment denial

Incomplete or inaccurate information may lead to payment denial. The submitting provider certifies the information is true, accurate, and complete. Note: Payment is subject to member eligibility; authorization does not guarantee payment.

Incomplete or inaccurate information may lead to payment denial
Authorization does not guarantee payment; payment subject to member eligibility
Provider certifies information is true, accurate, and complete

Background

This prior authorization form collects the clinical data needed to support initiation or continuation of testosterone therapy for approved indications. It documents whether the member has primary hypogonadism (with causes such as bilateral orchidectomy, cryptorchidism, torsion, orchitis, Klinefelter’s syndrome, chemotherapy/radiation/toxic/surgical damage, etc.) or secondary hypogonadism due to hypopituitarism, as well as other approved indications including delayed puberty, metastatic breast cancer for palliative treatment, and requests related to gender dysphoria.

To substantiate medical necessity the form requests objective laboratory confirmation (the two morning total and free testosterone measurements) plus documentation of clinical symptoms/signs and, for reauthorization, evidence of a positive clinical response and a recent total testosterone level within the past 12 months.

Definitions

inv-11: Primary hypogonadism — causes listed (e.g., bilateral orchidectomy, cryptorchidism, torsion, orchitis, Klinefelter's, chemotherapy/radiation)

DefinitionPrimary hypogonadism: testicular failure due to specified causes (e.g., bilateral orchidectomy, cryptorchidism, bilateral torsions, orchitis, vanishing testis syndrome, single orchidectomy, Klinefelter's syndrome, chemotherapy damage, radiation damage, toxic damage, surgical damage)

Examples — surgical causesBilateral orchidectomy, single orchidectomy, vanishing testis syndrome, surgical damage

Examples — developmental/geneticCryptorchidism, Klinefelter's syndrome

Examples — infectious/vascularOrchitis, bilateral torsions

Examples — treatment/toxic injuryChemotherapy damage, radiation damage, toxic damage

inv-12: Secondary hypogonadism — due to hypopituitarism or pituitary hormone deficiencies

DefinitionSecondary hypogonadism: hypogonadism due to hypopituitarism or pituitary hormone deficiencies

Documentation promptForm specifically asks whether the member has secondary hypogonadism due to hypopituitarism (pituitary hormone deficiencies) with Yes/No response

Relation to coverage criteriaSecondary hypogonadism is an accepted diagnostic indication to support testosterone therapy when documented