Affected CPT codes — no PA specifics

No explicit prior authorization requirements are listed in this policy; the CPT codes associated with testosterone and related hormone testing are 82040, 82642, 82670, 82681, 84270, 84402, 84403, and 84410 and may be affected by the coverage criteria in this policy.

• Affected CPT codes: 82040, 82642, 82670, 82681, 84270, 84402, 84403, 84410

Confirmatory testing before initiating therapy

Prior authorization (when required by the plan) is expected to include documentation of clinical symptoms consistent with testosterone deficiency plus unequivocally low total testosterone confirmed on two separate early-morning measurements, with supporting hormone tests (e.g., LH/FSH, prolactin) and baseline labs (hematocrit) per guideline diagnostic pathways.

• Two total testosterone measurements on separate early-morning occasions demonstrating unequivocally low TT
• Document clinical symptoms or signs consistent with testosterone deficiency
• Include adjunct hormone testing (LH/FSH, prolactin) and baseline hematocrit/hemoglobin as applicable

Document castrate testosterone during ADT

For patients receiving androgen deprivation therapy (ADT) for prostate cancer, document castrate serum testosterone (<50 ng/dL) if clinically indicated and monitor PSA and testosterone every 3–6 months as recommended.

• Document castrate testosterone level: <50 ng/dL
• Monitor PSA and testosterone every 3–6 months during ADT

Prior authorization — coverage contingent on criteria and benefits

This excerpt does not provide specific prior authorization processes; coverage is contingent upon meeting the policy's clinical criteria and any applicable member benefit provisions—consult the member benefit booklet or customer service for plan-specific PA requirements.

• Coverage depends on meeting policy criteria and member benefit limits
• Contact member services or consult benefit booklet for PA details

Provider action — verify additional requirements

Placeholder: review source for any additional provider action not already captured in other callouts; if applicable, document specific requirement here.

Assess etiology and consider conservative management

Before considering long‑term testosterone therapy, assess underlying etiology (functional versus classical hypogonadism) and consider nonpharmacologic management such as weight loss for functional hypogonadism.

• Evaluate for functional versus classical hypogonadism (identify reversible causes)
• Consider conservative measures (e.g., weight loss) when appropriate prior to initiating long-term therapy

Tiered testing: total testosterone first

Use a tiered testing strategy: measure serum total testosterone first; reserve measurement or calculation of free/bioavailable testosterone for when total testosterone is equivocal or when conditions altering SHBG are present.

• Initial test: total testosterone (morning, validated assay)
• If TT borderline or SHBG-altering condition present, calculate or measure free/bioavailable testosterone

Provider action — verify additional testing/monitoring steps

Placeholder: review source for any additional provider action not already captured in other callouts; populate if specific actionable requirements are present.

Document two morning total testosterone measurements for initial screening

For initial screening of androgen deficiency in individuals assigned male at birth, obtain two serum total testosterone measurements at least 24 hours apart (early‑morning, fasting sample preferred) using an assay certified by the CDC HoSt/Testosterone program when possible.

• Two measurements at least 24 hours apart for initial screening
• Prefer early‑morning, fasting samples and CDC HoSt‑certified assays

Required diagnostic and baseline documentation before therapy

When diagnosing male hypogonadism, document two separate morning total testosterone measurements and record associated labs as indicated (LH/FSH, prolactin, SHBG/albumin) and baseline hematocrit/hemoglobin prior to initiating therapy.

• Two separate morning total testosterone measurements required for diagnosis
• Document LH/FSH, prolactin, SHBG/albumin when indicated and baseline hematocrit/hemoglobin

Document morning sample timing and repeat test on second morning

Document sample timing: collect testosterone samples in the morning (between 07:00–11:00) and, if an initial low value is obtained, repeat testing on a second morning prior to diagnosing hypogonadism or initiating therapy.

• Sample collection window: 07:00–11:00 (or within 3 hours of waking for shift workers)
• Repeat low TT on a second morning before diagnosing or treating

Document indication and verify member benefit coverage

When ordering serum total testosterone, document that the indication meets the policy's reimbursable criteria and be aware that member benefit limitations may apply—consult the member benefit booklet or customer service for plan-specific coverage details.

• Record the clinical indication linking testing to policy reimbursable criteria
• Check member benefit booklet or contact customer service for coverage limits

Salivary testosterone testing will be denied

Do not submit or rely on saliva-based testosterone tests for reimbursement—use of saliva for testosterone measurement is explicitly not reimbursable and will trigger denial when billed.

• Saliva testing for testosterone is excluded from reimbursement

Risk of inaccurate results from direct free‑T immunoassays

Avoid using direct analog‑based free testosterone immunoassays for clinical decision-making because they are inaccurate; reliance on these assays may lead to inappropriate clinical decisions and affect coverage.

• Do not use direct analog free‑T immunoassays; use calculated free T or equilibrium dialysis when indicated

Avoid hormone testing in isolated adrenarche

Do not order LH, FSH, and either estradiol or testosterone for children who present only with pubic hair and/or body odor without other signs of puberty (isolated premature adrenarche), as this testing is discouraged and may lead to unnecessary testing.

• Avoid LH/FSH and sex steroid testing in isolated pubic hair/body odor presentations

Denial triggers for primary free/bioavailable tests and asymptomatic testing

Claims for measurement of serum free testosterone and/or bioavailable testosterone submitted as primary tests (without prior total testosterone) or for asymptomatic individuals or those with nonspecific symptoms are not reimbursable per the corrected policy effective Sept 4, 2026.

• Free/bioavailable testosterone as a primary test is excluded from reimbursement
• Testing for asymptomatic or non‑specific symptoms is not reimbursable