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DESCRIPTIONTestosterone is an endogenous androgen. Androgens are responsible for normal growth and development of male sex organs. Testosterone is produced by the testes and is involved in the growth and maturation of the prostate, seminal vesicles, penis, and scrotum; development of male hair distribution (e.g., beard, pubic, chest and axillary hair); laryngeal enlargement, vocal cord thickening, and alterations in body musculature and fat distribution. In women, small amounts of testosterone are produced by the ovaries and adrenal glands. As in men, testosterone is thought to influence pubertal development, sexual function, bone density, muscle mass, erythropoiesis, energy, cognitive function, and mood in women.
Free Testosterone Measurement in Males
In short, obese men may have a low total serum testosterone concentration because of a combination of low SHBG and secondary hypogonadism. Measurement of the serum free testosterone concentration is necessary to determine if an obese man’s low total testosterone is due only to low SHBG or to secondary hypogonadism as well. Measurement of the serum free testosterone concentration is worthwhile only when it is suspected that an abnormality in testosterone binding to sex hormone-binding globulin coexists with hypogonadism. Measurement of the serum free testosterone in a laboratory capable of performing this assay accurately will distinguish between a binding abnormality and hypogonadism in an obese male.
Free Testosterone Measurement in Females
If serum free testosterone is measured, the following points should be kept in mind:
POLICYMeasurement of serum free testosterone is considered medically necessary to distinguish between a sex hormone-binding globulin (SHBG) abnormality and hypogonadism in obese males with symptoms of hypogonadism (See Policy Guidelines) if the total serum testosterone level is low.
Measurement of serum free testosterone is considered medically necessary to diagnose hyperandrogenism in symptomatic females (See Policy Guidelines).
Measurement of serum free testosterone is considered medically necessary in patients with a medical diagnosis that may increase or decrease SHBG levels (See Policy Guidelines).
Measurement of serum free testosterone is considered not medically necessary to diagnose testosterone deficiency in non-obese males with symptoms of hypogonadism.
Measurement of serum free testosterone is considered not medically necessary when performed for screening purposes in asymptomatic patients (absence of signs, symptoms, or disease).
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Symptoms hypogandism in males covered under this policy are malaise, fatigue, lethargy, hot flashes, muscle loss, depression, or decreased libido. If the only symptom is Erectile Dysfunction or Impotence, the laboratory testing is not covered.
Symptoms of overproduction of androgens in females include the following:
Medical diagnoses affected SHBG levels include the following:
Benefits will not be provided for the following contract exclusions:
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
POLICY HISTORY10/01/2013: New policy added.
08/18/2015: Medical policy revised to add ICD-10 codes.
01/15/2016: Code Reference section updated to make the following corrections: N64.9 should be L64.9 and N65.9 should be L65.9.
06/07/2016: Policy number L.2.04.405 added. Policy Guidelines updated to add medically necessary definition.
09/08/2016: Code Reference section updated to make correction: ICD-10 diagnosis code D27.01 should be D27.9.
09/30/2016: Code Reference section updated to add new ICD-10 diagnosis codes N83.201 - N83.299.
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.