Clinical UM Guideline

This document addresses laboratory testing of human chorionic gonadotropin (hCG) in urine or blood.

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

Medically Necessary:

Urine hCG testing is considered medically necessary for confirming the presence or absence of pregnancy.

Blood hCG testing is considered medically necessary for any of the following indications:

1. Confirming presence or absence of pregnancy; or
2. Screening pregnant individuals for fetal abnormalities; or
3. Hypertensive disorders of pregnancy; or
4. Gestational trophoblastic neoplasia or molar pregnancy; or
5. Evaluation of germ cell tumors; or
6. Testicular cancer or suspicious testicular mass; or
7. Ovarian cancer; or
8. Pelvic mass; or
9. Mediastinal mass; or
10. Retroperitoneal mass; or
11. Thymomas or thymic cancer; or
12. Cancer of unknown primary

Not Medically Necessary:

Urine or blood hCG testing is considered not medically necessary when the above criteria are not met.

This document describes clinical studies and expert recommendations and explains when a blood test that checks a certain pregnancy hormone level (human chorionic gonadotropin [hCG]) is appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

hCG is a hormone made during pregnancy. It helps stop menstruation and supports the development of the uterus as the embryo grows. It can be found in a pregnant person's blood and urine. At-home pregnancy tests detect a part of hCG found in urine. Blood or urine tests for hCG can confirm pregnancy or check for a pregnancy loss. Doctors may also check hCG levels to look for abnormalities in the developing baby during pregnancy or to help diagnose and manage certain cancers. These cancers may include testicular cancer, ovarian cancer, tumors in the chest area, or cancers of unknown origin. Very high hCG levels in someone who is not pregnant may mean they have one of these diseases. However, high levels can sometimes happen for other reasons, such as hormone problems or marijuana use. Because of this, it is important to follow a step-by-step approach when checking hCG levels.

What the Studies Show

Studies show that checking hCG helps in many situations. During pregnancy, it can help identify chromosomal conditions and neural tube defects when used with other tests. In the second trimester, high hCG levels may help predict conditions like preeclampsia, which can harm both the pregnant person and the fetus. High hCG can also signal a type of pregnancy-related tumor called gestational trophoblastic disease. When this happens, hCG levels are checked before, during, and after treatment.

hCG is also an important marker for germ cell tumors, a type of cancer that starts in cells that usually make sperm or eggs. These tumors can appear in the testicles (also called the testes), ovaries, or other parts of the body. High hCG levels are common in people with these tumors. Expert groups recommend checking hCG levels for people with these conditions at several points: before and after surgery, before chemotherapy, and during follow-up. Experts also say hCG can help in planning surgery and watching for the return of cancer. When hCG is found in a person who is not pregnant and does not have cancer, further testing is needed.

When is hCG Testing Clinically Appropriate?

hCG testing may be appropriate in these situations:

• To confirm pregnancy or pregnancy loss
• In the first or second trimester of pregnancy to assess risk of fetal chromosomal conditions and neural tube defects
• To evaluate for preeclampsia during pregnancy
• To help diagnose and monitor gestational trophoblastic disease
• To evaluate a testicular or ovarian mass that may be a germ cell tumor
• As part of staging and treatment monitoring in people with known germ cell tumors of the testes or ovaries.
• To evaluate chest or abdominal masses that may be germ cell tumors
• When assessing cancer of unknown origin, especially if the tumor is in the chest or abdomen

When is this not Clinically Appropriate?

hCG testing is not clinically appropriate when used without clear medical reason. For example, if a person is not pregnant and does not have signs of cancer, high hCG alone is not enough to start treatment. Better studies are needed to know if checking hCG in other situations improves health. Testing should always follow a careful approach to avoid mistakes in diagnosis or treatment. hCG testing is not clinically appropriate in scenarios other than those listed above. Unnecessary or unproven tests can lead to needless worry or to treatment that does not help.

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The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Medically Necessary:

When services are Not Medically Necessary:
For the procedure code listed above for all other diagnoses not listed.

Summary

Human chorionic gonadotropin (hCG) is a hormone produced by the placenta during pregnancy that supports implantation and early fetal development. It becomes detectable in blood and urine approximately 11 days after conception, peaks near the end of the first trimester, and then declines, disappearing after birth. Measurement of hCG is central to confirming pregnancy, assessing pregnancy loss, and screening for fetal abnormalities. Professional guidelines recommend using hCG alone or in combination with other markers such as alpha-fetoprotein (AFP), pregnancy-associated plasma protein A, unconjugated estriol, and inhibin-A during the first and second trimesters to estimate the risk of chromosomal abnormalities and neural tube defects. Elevated hCG levels, particularly in the second trimester, are also associated with hypertensive disorders of pregnancy such as preeclampsia and other adverse outcomes. The American College of Obstetricians and Gynecologists (ACOG) provides recommendations supporting the use of hCG in pregnancy.

Outside of normal pregnancy, hCG is an important tumor marker. It is a sensitive indicator for gestational trophoblastic diseases, including molar pregnancy and malignant trophoblastic neoplasms, and is used to diagnose, monitor treatment response, and detect recurrence. Elevated hCG can also indicate the presence of germ cell tumors of the testes, ovaries, or extragonadal sites such as the mediastinum or retroperitoneum, as well as certain cancers of unknown primary. Multiple clinical guidelines, including ACOG, the American Society of Clinical Oncology (ASCO), the American Urological Association (AUA), and the National Comprehensive Cancer Network (NCCN), recommend routine hCG testing for diagnosis, staging, prognosis, treatment monitoring, and surveillance in these cancers. However, mildly elevated hCG can occur due to nonmalignant causes, and professional societies emphasize a systematic evaluation to rule out pregnancy, malignancy, and false positives before pursuing invasive testing or treatment.

Discussion

Human chorionic gonadotropin (hCG) is a hormone made by the placenta during pregnancy. It signals the body to stop menstruation and promotes thickening of the uterine lining to support a growing embryo. During pregnancy, hCG can be found in the amniotic fluid and in the pregnant person’s blood and urine. Part of the hCG molecule, the beta subunit (β-hCG), is degraded in the kidney to make a core fragment that can be measured by urine hCG tests such as a typical at-home pregnancy test.

Measuring hCG levels in blood or urine is done to identify a pregnancy and can also be useful to confirm pregnancy loss. hCG is first found in urine or blood around 11 days after conception. hCG levels are the highest toward the end of the first trimester (10 weeks of pregnancy), then decline for the rest of the pregnancy. hCG disappears after birth and is not normally detectable in a healthy non-pregnant person.

hCG testing may also be performed during pregnancy to detect fetal abnormalities. A 2020 committee opinion by the ACOG recommended testing pregnant persons in the first trimester of pregnancy (10 to 14 weeks of gestation) for hCG along with pregnancy associated plasma protein A, and alpha-fetoprotein (AFP). A risk estimate for common fetal chromosomal abnormalities (generally trisomies 13, 18, and 21) can be calculated using these test results along with other information known about the pregnant person such as age, history of aneuploidy, weight, race, and number of fetuses. hCG measurements may also be performed during the second trimester as part of a combined screening for chromosome abnormalities and neural tube defects. This screening includes testing parental serum levels of hCG, AFP, unconjugated estriol and/or inhibin-A.

Hypertensive disorders of pregnancy can lead to adverse outcomes for both the pregnant individual and the fetus. hCG levels, especially during the second trimester, are valuable clinical predictors of preeclampsia (Zhang, 2021). High hCG levels are associated with a high incidence of pregnancy complications including preeclampsia, placental abruption and prenatal death (Huang, 2022).

In addition to pregnancy, hCG may be produced in some disease conditions. Gestational trophoblastic disease (GTD) is a condition in which a tumor develops from abnormal tissue that forms after conception. The most common type of GTD is hydatidiform mole (HM), also called a molar pregnancy. HM is a benign premalignant disease. Malignant forms of GTD, known as gestational trophoblastic neoplasia, include invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. hCG is a sensitive marker to indicate the presence or absence of these diseases before, during, and after treatment.

Elevated levels of hCG when a person is not pregnant may indicate the presence of extra-uterine cancers such as germ cell tumors. Germ cells normally form sperm or eggs. A germ cell tumor (GCT) arises from these reproductive cells. These occur most commonly in the testes or ovaries. GCTs account for approximately 95% of testicular cancers but they occasionally originate in extragonadal sites such as the mediastinum or retroperitoneum. GCTs can be benign or malignant. When GCTs involve the testes, they can be further divided into seminomas and nonseminomatous tumors (also known as nonseminomas). Seminomas are typically located in the testes while nonseminomas are cancerous tumors commonly found in the pineal gland in the brain, the mediastinum, or the abdomen. Elevation of hCG is found in approximately 14% of individuals with stage I seminomas before orchiectomy and in about half of individuals with metastatic seminomas. Approximately 40% to 60% of those with nonseminomas have an elevated blood hCG.

A 2010 guideline on uses of serum tumor markers in adult males with germ cell tumors by ASCO provided recommendations for appropriate uses for serum markers of GCTs. The guideline recommends measuring 3 markers (hCG, AFP and lactate dehydrogenase [LDH]) before and after orchiectomy to stage patients with testicular nonseminomas, and before chemotherapy to stage those with extragonadal nonseminomas. They also recommended measuring hCG and AFP shortly before retroperitoneal lymph node dissection and at the start of each chemotherapy cycle for nonseminomas, and periodically to monitor for relapse. The guideline recommended measuring postorchiectomy hCG and LDH for individuals with seminoma who had elevated levels of these markers prior to orchiectomy. They also recommended measuring hCG and AFP to monitor for relapse in individuals treated for advanced seminoma.

In 2024 AUA published guidelines for the diagnosis and treatment of early stage testicular cancer. These guidelines recommend testing for elevated hCG in individuals with a solid testicular mass that is suspicious for cancer. This testing should be done prior to any treatment, including orchiectomy (moderate recommendation, grade C).

According to NCCN’s 2026 guideline for testicular cancer, hCG is the most commonly elevated serum tumor marker in testicular cancer. Elevated serum concentrations of hCG may be present with both seminomas and nonseminomas. NCCN states that hCG levels are critical for determining prognosis and assessing treatment outcomes in individuals with testicular GCTs. hCG should be measured before and after treatment and throughout the follow-up period. However, further workup should be considered before initiating treatment for mildly elevated hCG since other factors, including hypogonadism and marijuana use, can cause false positive results.

The NCCN 2025 guideline for ovarian cancer states that hCG, along with other tumor markers including but not limited to AFP and LDH, may provide important information in the preoperative workup. Ovarian germ cell tumors can cause high levels of hCG while other types of ovarian tumors do not. hCG, AFP, and LDH are markers for malignant germ cell tumors that can be helpful in diagnosis, preoperative planning, and post-treatment monitoring for recurrence.

A mass in the mediastinum often stems from the thymus gland but could be a GCT. The 2026 NCCN guideline for thymomas and thymic carcinomas recommends hCG testing in the initial evaluation of mediastinal masses to rule out a GCT.

Cancers of unknown primary are metastatic tumors whose primary site of origin cannot be determined during standard pretreatment evaluation. The NCCN 2026 guideline for occult primary (cancer of unknown primary [CUP]) recommends measurement of hCG when there is a mediastinal or retroperitoneal mass as it may be suggestive of a primary GCT. Identification of a GCT is important as GCTs are effectively treated with combination chemotherapy, and appropriate therapy may lead to cure.

ACOG (2026) provides the following recommendations for the management of positive hCG in individuals who are not pregnant and do not have a gynecologic malignancy:

Positive hCG test results have been associated with unnecessary workup and treatment, including invasive procedures and chemotherapy. It is important for health care professionals to consider alternative explanations for positive hCG results when pregnancy and malignancy have been excluded, particularly before proceeding with more invasive interventions. Due to the multiple potential etiologies of persistently elevated hCG, health care professionals should evaluate test results according to a systematic framework. When serum hCG test results are elevated, the first steps are to evaluate for pregnancy (both intrauterine and ectopic). Appropriate retesting to rule out various etiologies and to identify the main cause of persistently elevated hCG is necessary to avoid misdiagnosis or mismanagement of elevated hCG levels.

Hydatidiform mole: A mass that forms in the uterus early in pregnancy made up of cells from an abnormally developed embryo and placenta.

Mediastinum: The central compartment between the lungs in the thoracic cavity. The mediastinum contains the heart and all the organs in the chest cavity, with the exception of the lungs themselves.

Orchiectomy: Surgery to remove one or both testicles.

Peritoneum: The tissue that lines the abdominal wall and covers most of the organs in the abdomen.

Preeclampsia: A condition in pregnancy characterized by high blood pressure, fluid retention and proteinuria.

Retroperitoneum: The area in the abdomen behind the peritoneum.

Trophoblastic: Pertaining to embryonic cells that facilitate attachment to the uterus and formation of the placenta.

Peer Reviewed Publications:

1. Huang J, Liu Y, Yang H, et al. The Effect of Serum β-human chorionic gonadotropin on pregnancy complications and adverse pregnancy outcomes: a systematic review and meta-analysis. Comput Math Methods Med. 2022; 2022:8315519.
2. Nicholson BD, Jones NR, Protheroe A, et al. The diagnostic performance of current tumour markers in surveillance for recurrent testicular cancer: a diagnostic test accuracy systematic review. Cancer Epidemiol. 2019; 59:15-21.
3. Zhang X, Huangfu Z, Shi F, Xiao Z. Predictive Performance of Serum β-hCG MoM Levels for Preeclampsia Screening: A Meta-Analysis. Front Endocrinol (Lausanne). 2021; 12:619530.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Alldred SK, Takwoingi Y, Guo B, et al. First and second trimester serum tests with and without first trimester ultrasound tests for Down's syndrome screening. Cochrane Database Syst Rev. 2017; 3(3):CD012599.
2. American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice, Society for Maternal-Fetal Medicine. Indications for outpatient antenatal fetal surveillance: ACOG Committee Opinion, Number 828. Obstetrics and gynecology. 2021; 137(6):e177-e197.
3. American College of Obstetricians and Gynecologists Clinical Consensus No. 11: Management of positive human chorionic gonadotropin test results in nonpregnant patients without gynecologic malignancy. Obstet Gynecol. 2026; 147(2):e32-e38.
4. American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Screening for fetal chromosomal abnormalities: ACOG Practice Bulletin, Number 226. Obstetrics and gynecology. 2020; 136(4):e48-e69.
5. Centers for Disease Control and Prevention. Diagnosis of birth defects. Reviewed November 22, 2024. Available at: https://www.cdc.gov/birth-defects/screening/diagnosis.html?CDC_AAref_Val=https://www.cdc.gov/ncbddd/birthdefects/diagnosis.html. Accessed on January 27, 2026.
6. Centers for Disease Control and Prevention. How to be reasonably certain that a patient is not pregnant. Reviewed November 19, 2024. Available at: https://www.cdc.gov/contraception/hcp/usspr/not-pregnant.html. Accessed on January 27, 2026.
7. Gilligan TD, Seidenfeld J, Basch EM, et al. American Society of Clinical Oncology clinical practice guideline on uses of serum tumor markers in adult males with germ cell tumors. J Clin Oncol. 2010; 28(20):3388-3404.
8. National Cancer Institute. Gestational trophoblastic disease treatment. Updated July 19, 2024. Available at: https://www.cancer.gov/types/gestational-trophoblastic/hp/gtd-treatment-pdq. Accessed on January 27, 2026.
9. National Cancer Institute. Infantile choriocarcinoma of the liver. Updated December 19, 2024.Available at: https://www.cancer.gov/types/liver/childhood-liver-cancer/infantile-choriocarcinoma. Accessed on January 27, 2026.
10. National Cancer Institute. Ovarian germ cell tumors treatment (PDQ^®) -Health Professional Version. Revised September 18, 2025. Available at: https://www.cancer.gov/types/ovarian/hp/ovarian-germ-cell-treatment-pdq. Accessed on January 27, 2026.
11. National Cancer Institute. Testicular cancer treatment (PDQ^®) -Patient Version. Revised May 17, 2023. Available at: https://www.cancer.gov/types/testicular/patient/testicular-treatment-pdq. Accessed on January 27, 2026.
12. NCCN Clinical Practice Guidelines in Oncology^®. © 2026 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website: http://www.nccn.org/index.asp. Accessed on January 27, 2026.
    • Gestational Trophoblastic Neoplasia (V2.2026). Revised November 21, 2025.
    • Occult Primary (Cancer of Unknown Primary [CUP]) (V1.2026). Revised October 15, 2025.
    • Ovarian Cancer including Fallopian Tube Cancer and Primary Peritoneal Cancer (V3.2025). Revised July 16, 2025.
    • Testicular Cancer (V1.2026). Revised October 15, 2025.
    • Thymomas and Thymic Carcinomas (V1.2026). Revised October 03, 2025.
13. Stephenson A, Bass EB, Bixler BR, et al. Diagnosis and treatment of early-stage testicular cancer: AUA guideline amendment 2023. J Urol. 2024; 211(1):20-25.
14. Sturgeon CM, Duffy MJ, Stenman UH, et al. National Academy of Clinical Biochemistry Laboratory Medicine practice guidelines for use of tumor markers in testicular, prostate, colorectal, breast, and ovarian cancers. Clin Chem. 2008; 54(12):e11-79.

1. American Cancer Society. Tests for Testicular Cancer. Last revised: August 10, 2025. Available at: https://www.cancer.org/cancer/testicular-cancer/detection-diagnosis-staging/how-diagnosed.html. Accessed on January 27, 2026.
2. American Cancer Society. Treatment for Germ Cell Tumors of the Ovary. Last revised: April 8, 2025. Available at: https://www.cancer.org/cancer/ovarian-cancer/treating/germ-cell-tumors.html. Accessed on January 27, 2026.
3. American Cancer Society. What is Testicular Cancer? Last revised: August 10, 2025. Available at: https://www.cancer.org/cancer/testicular-cancer/about/what-is-testicular-cancer.html. Accessed on January 27, 2026.
4. United States Food and Drug Administration. Home Use Tests/ Pregnancy. Last reviewed: April 29, 2019. Available at: https://www.fda.gov/medical-devices/home-use-tests/pregnancy. Accessed on January 27, 2026.

β-hCG
hCG
human chorionic gonadotropin

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