Testosterone Replacement or Supplementation Therapy

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UnitedHealthcare Commercial Medical Benefit Drug Policy Testosterone Replacement or Supplementation Therapy Policy Number: 2022D0076E. Effective Date: January 1, 2022 Instructions for Use Table of Contents Page Community Plan Policy Coverage Rationale ........................................ ............................... 1 Testosterone Replacement or Supplementation Applicable Codes ........................................ .................................. 3 Therapy 6. Benefit Considerations ........................................ .......................... 6. Clinical Evidence ........................................ ................................... 7. Food and Drug Administration ........................................ ..... 7. References.

­ Aromatase inhibitor (e.g., Arimidex [anastrozole], Femara [letrozole], Aromasin [exemestane]) and Patient was male at birth; and Diagnosis of hypogonadism; and One of the following: ­ Significant reduction in weight (˂ 90% ideal body weight) (e.g., AIDS wasting syndrome); or ­ Osteopenia; or ­ Osteoporosis; or

  Patients, Replacement, Therapy, Testosterone, Supplementation, Letrozole, Testosterone replacement or supplementation therapy