MP-07 Circumcision Form

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Medical Policy
Circumcision
Current Effective Date: 03/23/2016 Original Effective Date: 01/20/2014
Next Review/Revision Date: 10/16/2015
Line of Business: QUEST Integration (QI)

Definition

Circumcision is surgery to remove the foreskin.

Criteria

1. AlohaCare will cover circumcision for newborns (the first 30 days of life) whose mothers are AlohaCare QI members.
2. AlohaCare will cover circumcision for children under 19 years old.
3. AlohaCare will cover circumcision for adult members (≥19 years old) based on medical necessity if one of the following conditions is present:
   a. Recurrent urinary tract infection
   b. Vesicoureteral reflux of at least a Grade III
   • Grade III: Urinary reflux into the ureter and collecting system. The ureter and pelvis appear mildly dilated, and the calyces are mildly blunted.
   • Grade IV: Reflux into the ureter and collecting system. The ureter and pelvis appear moderately dilated, and the calyces are moderately blunted.
   • Grade V: Reflux into the ureter and collecting system. The pelvis is severely dilated, the ureter appears tortuous, and the calyces are severely blunted. c. Urgent paraphymosis
   e. Recurrent balanoposthitis occurs after treatment of penile hygiene and topical antibiotics.
   f. True phimosis causing urinary obstruction, hematuria or preputial pain. True phimosis is defined as pathological scarring of the prepuce preventing sufficient retraction of the prepuce to visualize the glans.
   • The phimosis interferes with erection
   • The phimosis interferes with urination
   • The member has pain on attempted foreskin retraction

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Medical Policy
Circumcision
• The phimosis causes recurrent infection, posthitis and/or penile cellulitis.
g. Condyloma acuminatum
h. Malignant neoplasm of the prepuce
i. Genital warts on foreskin (human papilloma virus)
j. Tears in the frenulum
k. Trauma to the foreskin

4. AlohaCare will cover lysis post‐circumcision adhesions.

5. AlohaCare will cover the repair of incomplete circumcision when excessive residual prepuce remains after a previous medically necessary circumcision.

   Guidelines
   Prior authorization is not required.

   Limitations

6. The following procedure are covered only once per lifetime:
   a. Circumcision
   b. Repair of incomplete circumcision

   Coding Information
   The following medical codes are relevant codes for diagnosis and procedures for circumcision and for informational purposes only. All the medical codes listed in this policy do not constitute or imply benefit coverage or provider reimbursement.

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Medical Policy
Circumcision

771.82
Urinary tract infection of newborn
922.4
Contusion of genital organs
V20.1
Health supervision of other healthy infant or child receiving care
V20.2
Routine infant or child health check
V30.0‐V39.2
Live newborn
V50.2
Routine or ritual circumcision

ICD‐10‐CM
Description
A06.82
Circumcision, using clamp or other device with regional dorsal penile or ring block

A54.09
Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28

days of age or less)

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Medical Policy
Circumcision
A57
Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28

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Medical Policy
Circumcision

days of age
A74.89
Lysis or excision of penile post‐circumcision adhesions
B07.9
Repair incomplete circumcision
B37.42
Candidal balanitis
C60.0
Malignant neoplasm of prepuce
D07.4
Carcinoma in situ of penis
D29.0
Benign neoplasm of penis
N13.71
Vesicoureteral‐reflux without reflux nephropathy
N13.721
Vesicoureteral‐reflux with reflux nephropathy without hydroureter, unilateral

N13.722
Vesicoureteral‐reflux with reflux nephropathy without hydroureter, bilateral
N13.729
Vesicoureteral‐reflux with reflux nephropathy without hydroureter, unspecified
N13.731
Vesicoureteral‐reflux with reflux nephropathy with hydroureter, unilateral
N13.732
Vesicoureteral‐reflux with reflux nephropathy with hydroureter, bilateral
N13.739
Vesicoureteral‐reflux with reflux nephropathy with hydroureter, unspecified
N39.0
Urinary tract infection, site not specified
N47.1
Phimosis
N48.0
Leukoplakia of penis
N48.1
Balanitis
P39.3
Neonatal urinary tract infection

CPT
Description
54150
Circumcision, using clamp or other device with regional dorsal penile or ring block
54160 Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less)
54161 Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age
54162 Lysis or excision of penile post‐circumcision adhesions
54163 Repair incomplete circumcision

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Medical Policy
Circumcision

References/Resources

Document Name
Effective Date
Source/Link
Circumcision Policy
08/27/2012
American Academy of Pediatrics (AAP)
Statement
http://pediatrics.aappublications.org/content/earl y/2012/08/22/peds.2012‐1989
Medical Studies on
Past 10 years
Circumcision Resource Center
Circumcision
literature reviews http://www.circumcision.org/studies.htm
Medicaid Funding for
N/A
Circumcision Resource Center
Circumcision
http://www.circumcision.org/medicaid.htm
Circumcision Guidelines By
08/27/2012
Huff Post Parents
the AAP Have Been Revised http://www.huffingtonpost.com/2012/08/27/newFor the First Time Since 1999
circumcision‐guidelinn1826069.html
Benefits of Infant
08/27/2012
CNN
Circumcision Outweigh Risks,
http://www.cnn.com/2012/08/27/health/circumci Top Pediatrics Group Says
sion‐policy/index.html

Review/Revision History

1. Reviewed on 06/16/2014, AlohaCare no longer requires prior authorization for adults. Please see the revision in Guidelines.
2. Reviewed on 03/23/2016. Corrected the line of business.