CurrentHumanaPolicy LAB2023005

Laboratory - Hormone Testing

Medicare Advantage payment policy for hormone laboratory testing (test types, indications, and frequencies) that governs claims payment for Humana Medicare Advantage members and guides providers on reimbursable and non-reimbursable hormone tests.

Policy Summary

PayerHumana

PolicyLaboratory - Hormone Testing

Policy CodePolicy LAB2023005

Change TypeNo material clinical or coverage changes

Effective DateMar 1, 2023

Next Review Date

Key ActionDocument the clinical indication that matches listed reimbursable conditions and the applicable testing frequency when submitting claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=8listed clinical indications reimbursable for free testosterone measurement

up to 8 / 4ymax reimbursable total testosterone tests (TRT)

7applicable procedure codes enumerated

1estradiol testing frequency for gynecomastia

Coverage Criteria for Hormone Testing

Reimbursable indications for free/bioavailable testosterone

Measurement of serum free testosterone (via total testosterone 84403, SHBG 84270, or bioavailable testosterone 84410) is covered when any of the following conditions are present:

Reimbursable clinical indications: Acromegaly; Acute and chronic kidney failure; Benign prostatic hypertrophy; Cirrhosis and hepatitis; Diabetes mellitus; Erectile dysfunction; HIV disease; Hyperthyroidism; Hypothyroidism; Infertility; Nephrotic syndrome; Obesity; Polymorphisms; Use of estrogens; Use of glucocorticoids, progestins and androgenic steroids

From policy list

Specific covered situations for total testosterone

Testing for serum total testosterone (84403) is covered in any of the following situations:

Covered situations: Individuals taking enzyme inhibitors for prostate cancer; Individuals receiving testosterone replacement therapy (up to eight tests every four years); Gender‑dysphoric or gender‑incongruent persons; Infertility

Policy Summary

PayerHumana

PolicyLaboratory - Hormone Testing

Policy CodePolicy LAB2023005

Change TypeNo material clinical or coverage changes

Effective DateMar 1, 2023

Next Review Date

Key ActionDocument the clinical indication that matches listed reimbursable conditions and the applicable testing frequency when submitting claims.

SourceLink

On This Page

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.

Provider Actions, Documentation, and Billing Notes

Prior Authorization

No prior authorization requirements are stated in this policy for the laboratory hormone tests described on these pages.

Documentation Required

Required clinical indication and frequency documentation

Testing for serum total testosterone (CPT 84403), free testosterone (CPT 84402) or bioavailable testosterone (CPT 84410) is reimbursable only when the clinical indication matches listed conditions (e.g., acromegaly, kidney failure, diabetes, erectile dysfunction, infertility, use of estrogens or glucocorticoids, gender‑dysphoric persons, individuals on enzyme inhibitors for prostate cancer, or for monitoring testosterone replacement therapy up to eight tests every four years). Testing in asymptomatic individuals or for non‑specific symptoms is NOT reimbursable.

Affected codes: CPT 84403, CPT 84402, CPT 84410, CPT 84270
Reimbursable indications include: acromegaly; acute/chronic kidney failure; benign prostatic hypertrophy; cirrhosis/hepatitis; diabetes mellitus; erectile dysfunction; HIV; hyperthyroidism; hypothyroidism; infertility; nephrotic syndrome; obesity; polymorphisms; use of estrogens, glucocorticoids, progestins, androgenic steroids; individuals taking enzyme inhibitors for prostate cancer; gender‑dysphoric or gender‑incongruent persons; individuals receiving testosterone replacement therapy (monitoring: up to 8 tests every 4 years).
Not reimbursable: asymptomatic individuals or individuals with non‑specific symptoms.

Documentation Required

Documentation requirements

These pages do not specify additional documentation requirements beyond documenting the clinical indication and, where applicable, the frequency or treatment context described above.

Step Therapy

Step therapy

No step therapy requirements are specified in this policy for these laboratory tests.

Denial Risk

Denial risk for asymptomatic / non‑specific symptoms

Testing for serum total testosterone (CPT 84403), free testosterone (CPT 84402) or bioavailable testosterone (CPT 84410) in asymptomatic individuals or for non‑specific symptoms is a denial risk.

Affected codes: CPT 84403, CPT 84402, CPT 84410

Background and Clinical Context

Testosterone measurements (total, free, bioavailable) and related hormone assays such as SHBG, estradiol and dihydrotestosterone are used to evaluate and manage a range of endocrine and reproductive conditions. The policy clarifies reimbursable uses of these assays — for example, dihydrotestosterone (CPT 82642) is reimbursable for diagnosing 5‑alpha reductase deficiency in individuals with ambiguous genitalia, hypospadias or microphallus, and estradiol (CPT 82670, 82681) is reimbursable for gynecomastia (once per lifetime) and for infertility as needed. Conversely, testing for testosterone (CPT 84403, 84402, 84410) is not reimbursable in asymptomatic patients or those with non‑specific complaints, so testing should be targeted to the specific clinical indications enumerated in the policy.

Definitions and Test Descriptions

84410 — Testosterone; bioavailable, direct measurement

CPT code84410

DescriptionTestosterone; bioavailable, direct measurement (e.g., differential precipitation).

Typical useDirect measurement of bioavailable testosterone when estimation methods are inadequate or when clinical clarity is required.

82642 — Dihydrotestosterone (DHT)

CPT code82642

DescriptionDihydrotestosterone (DHT).

Covered indicationDiagnosing 5-alpha reductase deficiency in individuals with ambiguous genitalia, hypospadias or microphallus (policy-specified).

Bibliographic references supporting assay performance, reference intervals, and clinical associations

Key references — harmonized ranges & methodsTravison TG; Vesper HW; Orwoll E.; et al. (2017). Harmonized Reference Ranges for Circulating Testosterone Levels. J Clin Endocrinol Metab.

Analytical methods & validationvan der Veen A.; van Faassen M.; de Jong WHA.; et al. (2019). Development and validation of LC-MS/MS method for steroid hormones. Clin Biochem.

Free testosterone estimation critiqueVermeulen A.; Verdonck L.; Kaufman JM. (1999). Critical evaluation of simple methods for estimation of free testosterone. J Clin Endocrinol Metab.

Performance criteria & biological variationYun YM.; Botelho JC.; Chandler DW.; et al. (2012). Performance Criteria for Testosterone Measurements... Clin Chem.

Mechanistic binding modelZakharov MN.; Bhasin S.; Travison TG.; et al. (2015). Dynamic allosteric model of testosterone binding to SHBG. Mol Cell Endocrinol.

OpenPayer

Laboratory - Hormone Testing

Coverage Criteria for Hormone Testing

Applicable Procedure Codes

Provider Actions, Documentation, and Billing Notes

Background and Clinical Context

Definitions and Test Descriptions

Policy Revision History

82642	Dihydrotestosterone (DHT).
82670	Estradiol; total.
82681	Estrogens; fractionated.
84270	Sex hormone binding globulin (SHBG).
84402	Testosterone; free.
84403	Testosterone; total.
84410	Testosterone; bioavailable, direct measurement (e.g., differential precipitation).