Testosterone replacement therapy may be considered medically necessary under the following conditions:
An established diagnosis of hypogonadism with androgen deficiency (see Policy Guidelines section) that includes:
Persistently low testosterone levels, and
Multiple symptoms of hypogonadism including at least 1 «more specific» symptom (see Policy Guidelines section)
HIV-infected men with low testosterone levels and weight loss; or
Men on chronic steroid treatment with low testosterone levels (see Policy Guidelines section).
Testosterone replacement therapy is considered investigational in all other situations in which the above criteria are not met, including but not limited to older men with type 2 diabetes mellitus and androgen deficiency or low testosterone levels in the absence of clinical signs and symptoms of hypogonadism.