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L.2.04.412
Luteinizing hormone (LH) is a hormone released in both men and women by the anterior pituitary gland in the brain. Production of LH is controlled by the reproductive system, the pituitary gland, and the hypothalamus. Levels of LH in women fluctuate over time. In women, LH levels naturally increase in the middle of the menstrual cycle, causing ovulation. They also increase during menopause. In men, LH stimulates production of the hormone testosterone. Levels of LH remain fairly constant in men.
LH levels are useful in the investigation of menstrual irregularities and to aid in the diagnosis of pituitary disorders or diseases involving the ovaries or testes. LH may also be ordered when a boy or girl does not appear to be entering puberty at an appropriate age (either too late or too soon). Irregular timing of puberty may be an indication of a more serious problem involving the hypothalamus, the pituitary gland, the gonads (ovaries or testes), or other systems. The measurement of LH may differentiate between benign symptoms and true disease.
An abnormally high level of LH in the blood may indicate:
Abnormalities of the testes, including injury, tumor, infection, or damage from radiation or chemotherapy
Insufficient production of hormones by the sex glands
Menopause
Abnormalities or improper functioning of the ovaries, either due to problems with the ovaries themselves or due to problems with the pituitary or hypothalamus glands
Polycystic ovarian disease
Early onset of puberty
Conditions including Turner syndrome and Klinefelter syndrome
An abnormally low level of LH in the blood may indicate hypopituitarism or Kallmann syndrome.
Measurement of luteinizing hormone is considered medically necessary to distinguish between pituitary, hypothalamus, and gonad disorders in males with hypogonadism or hypergonadism.
Measurement of luteinizing hormone is considered medically necessary to distinguish between pituitary, hypothalamus, and gonad disorders in females with symptoms of ovarian dysfunction.
Measurement of luteinizing hormone is considered not medically necessary when performed for screening purposes in asymptomatic patients (absence of signs, symptoms, or disease).
None
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Benefits will not be provided for the following contract exclusions:
Services and supplies related to infertility, artificial insemination, intrauterine insemination and in-vitro fertilization regardless of any claim of Medical Necessity.
For treatment related to sex transformations, sexual function, sexual dysfunctions or inadequacies regardless of Medical Necessity.
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 Mental Health Disorders, 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 medical necessity, “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.
10/01/2013: New policy added.
08/18/2015: Medical policy revised to add ICD-10 codes.
06/07/2016: Policy number L.2.04.412 added. Policy Guidelines updated to add medically necessary definition.
09/30/2016: Code Reference section updated to add the following new ICD-10 diagnosis codes: N83.00 - N83.299 and N93.1.
09/29/2017: Code Reference section updated to revise description for ICD-10 diagnosis code Z79.890, effective 10/01/2017. Removed deleted ICD-10 diagnosis codes N83.0, N83.1, N83.20, N83.29 and ICD-9 diagnosis codes 620.0, 620.1, and 620.2.
09/29/2022: Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Code Reference section updated to add new ICD-10 diagnosis codes N80.00, N80.01, N80.02, N80.03, N80.101, N80.102, N80.103, N80.109, N80.111, N80.112, N80.113, N80.119, N80.121, N80.122, N80.123, N80.129, N80.201, N80.202, N80.203, N80.209, N80.211, N80.212, N80.213, N80.219, N80.221, N80.222, N80.223, N80.229, N80.30, N80.311, N80.312, N80.319, N80.321, N80.322, N80.329, N80.331, N80.332, N80.333, N80.339, N80.341, N80.342, N80.343, N80.349, N80.351, N80.352, N80.353, N80.359, N80.361, N80.362, N80.363, N80.369, N80.371, N80.372, N80.373, N80.379, N80.381, N80.382, N80.383, N80.389, N80.391, N80.392, N80.399, N80.3A1, N80.3A2, N80.3A3, N80.3A9, N80.3B1, N80.3B2, N80.3B3, N80.3B9, N80.3C1, N80.3C2, N80.3C3, N80.3C9, N80.40, N80.41, N80.42, N80.50, N80.511, N80.512, N80.519, N80.521, N80.522, N80.529, N80.531, N80.532, N80.539, N80.541, N80.542, N80.549, N80.551, N80.552, N80.559, N80.561, N80.562, N80.569, N80.A0, N80.A1, N80.A2, N80.A41, N80.A42, N80.A43, N80.A49, N80.A51, N80.A52, N80.A53, N80.A59, N80.A61, N80.A62, N80.A63, N80.A69, N80.B1, N80.B2, N80.B31, N80.B32, N80.B39, N80.B4, N80.B5, N80.B6, N80.C0, N80.C10, N80.C11, N80.C19, N80.C2, N80.C3, N80.C4, N80.C9, N80.D0, N80.D1, N80.D2, N80.D3, N80.D4, N80.D5, N80.D6, and N80.D9, effective 10/01/2022.
11/08/2022: Policy reviewed; no changes.
12/01/2023: Policy reviewed. Policy statements unchanged. Code Reference section updated to remove deleted ICD-10 diagnosis codes N80.0, N80.1, N80.2, N80.3, N80.4, and N80.5.
12/06/2024: Policy reviewed; no changes.
Endocrine Physician Advisory Committee
http://labtestsonline.org/understanding/analytes/lh/tab/test
Luteinizing Hormone Test By: Kohnle D, Arain S, Patient Education Reference Center (PERC), April 1, 2013
This 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.
Code Number | Description | ||
CPT-4 | |||
83002 | Gonadotropin; luteinizing hormone (LH) | ||
HCPCS | |||
ICD-9 Procedure | ICD-10 Procedure | ||
ICD-9 Diagnosis | ICD-10 Diagnosis | ||
174.0 - 174.9 | Malignant neoplasm of female breast | C50.011 - C50.019, C50.111 - C50.119, C50.211 - C50.219, C50.311 - C50.319, C50.411 - C50.419, C50.511 - C50.519, C50.611 - C50.619, C50.811 - C50.819, C50.911 - C50.919 | Malignant neoplasm of breast, excludes male |
183.0 | Malignant neoplasm of ovary | C56.1 - C56.9 | Malignant neoplasm of ovary |
186.0 - 186.9 | Malignant neoplasm of testis | C62.00 - C62.92 | Malignant neoplasm of testis |
194.0 - 194.9 | Malignant neoplasm of other endocrine glands and related structures | C74.00 - C74.92 | Malignant neoplasm of adrenal gland |
C75.0 - C75.9 | Malignant neoplasm of other endocrine glands and related structures | ||
220 | Benign neoplasm of ovary | D27.0 - D27.9 | Benign neoplasm of ovary |
227.0 - 227.9 | Benign neoplasm of other endocrine glands and related structures | D35.00 - D35.9 | Benign neoplasm of other and unspecified endocrine glands |
236.2 | Neoplasm of uncertain behavior of ovary | D39.10 - D39.12 | Neoplasm of uncertain behavior of ovary |
236.4 | Neoplasm of uncertain behavior of testis | D40.10 - D40.12 | Neoplasm of uncertain behavior of testis |
253.2 | Panhypopituitarism | E23.0 | Hypopituitarism (Panhypopituitarism) |
253.4 | Other anterior pituitary disorders | E23.6 | Other disorders of pituitary gland |
253.7 | Iatrogenic pituitary disorders | E23.1 | Drug-induced hypopituitarism |
256.0 | Hyperestrogenism | E28.0 | Estrogen excess |
256.1 | Other ovarian hyperfunction | E28.1 | Androgen excess |
256.31 | Premature menopause | E28.310 - E28.319 | Premature menopause |
256.39 | Other ovarian failure | E28.39 | Other primary ovarian failure |
256.4 | Polycystic ovaries | E28.2 | Polycystic ovarian syndrome |
257.1 | Postablative testicular hypofunction | E89.5 | Postprocedural testicular hypofunction |
257.2 | Other testicular hypofunction | E29.1 | Testicular hypofunction |
259.0 | Delay in sexual development and puberty, not elsewhere classified | E30.0 | Delayed puberty |
259.1 | Precocious sexual development and puberty, not elsewhere classified | E30.1 | Precocious puberty |
E30.8 | Other disorders of puberty | ||
E30.9 | Disorder of puberty, unspecified | ||
611.1 | Hypertrophy of breast | N62 | Hypertrophy of breast |
611.4 | Atrophy of breast | N64.2 | Atrophy of breast |
617.0 - 617.9 | Endometriosis | N80.00, N80.01, N80.02, N80.03 | Endometriosis of the uterus |
N80.101, N80.102, N80.103, N80.109 | Endometriosis of ovary, unspecified depth | ||
N80.111, N80.112, N80.113, N80.119 | Superficial endometriosis of the ovary | ||
N80.121, N80.122, N80.123, N80.129 | Deep endometriosis of ovary | ||
N80.201, N80.202, N80.203, N80.209 | Endometriosis of fallopian tube, unspecified depth | ||
N80.211, N80.212, N80.213, N80.219 | Superficial endometriosis of fallopian tube | ||
N80.221, N80.222, N80.223, N80.229 | Deep endometriosis of right fallopian tube | ||
N80.30 | Endometriosis of pelvic peritoneum, unspecified | ||
N80.311, N80.312, N80.319 | Endometriosis of the anterior cul-de-sac | ||
N80.321, N80.322, N80.329 | Endometriosis of the posterior cul-de-sac | ||
N80.331, N80.332, N80.333, N80.339 | Superficial endometriosis of the pelvic sidewall | ||
N80.341, N80.342, N80.343, N80.349 | Deep endometriosis of the pelvic sidewall | ||
N80.351, N80.352, N80.353, N80.359 | Endometriosis of the pelvic sidewall, unspecified depth | ||
N80.361, N80.362, N80.363, N80.369 | Superficial endometriosis of the pelvic brim | ||
N80.371, N80.372, N80.373, N80.379 | Deep endometriosis of the pelvic brim | ||
N80.381, N80.382, N80.383, N80.389 | Endometriosis of the pelvic brim, unspecified depth | ||
N80.391, N80.392, N80.399 | Endometriosis of other pelvic peritoneum | ||
N80.3A1, N80.3A2, N80.3A3, N80.3A9 | Superficial endometriosis of the uterosacral ligament(s) | ||
N80.3B1, N80.3B2, N80.3B3, N80.3B9 | Deep endometriosis of the uterosacral ligament(s) | ||
N80.3C1, N80.3C2, N80.3C3, N80.3C9 | Endometriosis of the uterosacral ligament(s), unspecified depth | ||
N80.40, N80.41, N80.42 | Endometriosis of rectovaginal septum and vagina | ||
N80.50 | Endometriosis of intestine, unspecified | ||
N80.511, N80.512, N80.519 | Endometriosis of the rectum | ||
N80.521, N80.522, N80.529 | Endometriosis of the sigmoid colon | ||
N80.531, N80.532, N80.539 | Endometriosis of the cecum | ||
N80.541, N80.542, N80.549 | Endometriosis of the appendix | ||
N80.551, N80.552, N80.559 | Endometriosis of other parts of the colon | ||
N80.561, N80.562, N80.569 | Endometriosis of the small intestine | ||
N80.A0, N80.A1, N80.A2 | Endometriosis of bladder and ureters | ||
N80.A41, N80.A42, N80.A43, N80.A49 | Superficial endometriosis of ureter | ||
N80.A51, N80.A52, N80.A53, N80.A59 | Deep endometriosis of ureter | ||
N80.A61, N80.A62, N80.A63, N80.A69 | Endometriosis of ureter, unspecified depth | ||
N80.B1 | Endometriosis of pleura | ||
N80.B2 | Endometriosis of lung | ||
N80.B31, N80.B32, N80.B39 | Endometriosis of diaphragm | ||
N80.B4 | Endometriosis of the pericardial space | ||
N80.B5 | Endometriosis of the mediastinal space | ||
N80.B6 | Endometriosis of cardiothoracic space | ||
N80.C0 | Endometriosis of the abdomen, unspecified | ||
N80.C10, N80.C11, N80.C19 | Endometriosis of the anterior abdominal wall | ||
N80.C2 | Endometriosis of the umbilicus | ||
N80.C3 | Endometriosis of the inguinal canal | ||
N80.C4 | Endometriosis of extra-pelvic abdominal peritoneum | ||
N80.C9 | Endometriosis of other site of abdomen | ||
N80.D0, N80.D1, N80.D2, N80.D3, N80.D4, N80.D5, N80.D6, N80.D9 | Endometriosis of the pelvic nerves | ||
N80.6 | Endometriosis in cutaneous scar | ||
N80.8 | Other endometriosis | ||
N80.9 | Endometriosis, unspecified | ||
N83.00 - N83.299 | Noninflammatory disorders of ovary, fallopian tube and broad ligament | ||
621.2 | Hypertrophy of uterus | N85.2 | Hypertrophy of uterus |
624.2 | Hypertrophy of clitoris | N90.89 | Other specified noninflammatory disorders of vulva and perineum |
626.0 | Absence of menstruation | N91.0 | Primary amenorrhea |
N91.1 | Secondary amenorrhea | ||
N91.2 | Amenorrhea, unspecified | ||
626.1 | Scanty or infrequent menstruation | N91.3 | Primary oligomenorrhea |
N91.4 | Secondary oligomenorrhea | ||
N91.5 | Oligomenorrhea, unspecified | ||
626.2 | Excessive or frequent menstruation | N92.0 | Excessive and frequent menstruation with regular cycle |
626.4 | Irregular menstrual cycle | N92.5 | Other specified irregular menstruation |
N92.6 | Irregular menstruation, unspecified | ||
626.6 | Metrorrhagia | N92.1 | Excessive and frequent menstruation with irregular cycle |
N93.1 | Pre-pubertal vaginal bleeding | ||
626.8 | Other disorder of menstruation and other abnormal bleeding from female genital tract | N93.8 | Other specified abnormal uterine and vaginal bleeding |
627.0 | Premenopausal menorrhagia | N92.4 | Excessive bleeding in the premenopausal period |
627.1 | Postmenopausal bleeding | N95.0 | Postmenopausal bleeding |
627.2 | Symptomatic menopausal or female climacteric states | N95.1 | Menopausal and female climacteric states |
627.3 | Postmenopausal atrophic vaginitis | N95.2 | Postmenopausal atrophic vaginitis |
627.4 | Symptomatic states associated with artificial menopause | N95.8 | Other specified menopausal and perimenopausal disorders |
704.00 | Alopecia, unspecified [Male pattern baldness in female] | L64.9 | Androgenic alopecia, unspecified |
704.1 | Hirsutism | L68.0 | Hirsutism |
706.1 | Other acne | L70.0 | Acne vulgaris |
L70.1 | Acne conglobata | ||
L70.3 | Acne varioliformis, acne necrotica miliaris | ||
L70.5 | Acne tropica | ||
L70.8 | Other acne | ||
706.3 | Seborrhea | L21.9 | Seborrheic dermatitis, unspecified |
758.6 | Gonadal dysgenesis | Q96.0 - Q96.9 | Turner's syndrome |
758.7 | Klinefelter's syndrome | Q98.0 | Klinefelter syndrome karyotype 47, XXY |
Q98.1 | Klinefelter syndrome, male with more than two X chromosomes | ||
Q98.3 | Other male with 46, XX karyotype | ||
Q98.4 | Klinefelter syndrome, unspecified | ||
780.8 | Generalized hyperhidrosis | R61 | Generalized hyperhidrosis |
782.62 | Flushing | R23.2 | Flushing |
799.81 | Decreased libido | R68.82 | Decreased libido |
V07.4 | Hormone replacement therapy (postmenopausal) | Z79.890 | Hormone replacement therapy |
V07.52 | Use of aromatase inhibitors | Z79.811 | Long term (current) use of aromatase inhibitors |
V07.59 | Use of other agents affecting estrogen receptors and estrogen levels | Z79.818 | Long term (current) use of other agents affecting estrogen receptors and estrogen levels |
V58.69 | Long-term (current) use of other medications | Z79.899 | Other long term (current) drug therapy |
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