Anthem Blue Cross Connecticut CG-SURG-103 Penile Circumcision Form
This procedure is not covered
Penile circumcision is a surgical procedure to remove the foreskin of the penis. This document addresses penile circumcision for individuals older than 4 weeks in corrected age (corrected age is defined as birth age minus the number of weeks a child is born prematurely).
Note: This document does not address routine penile circumcisions performed for the term or preterm infant in the newborn period.
Clinical Indications
Medically Necessary:
Penile circumcision is considered medically necessary when the individual has any of the following conditions:
- Preputial neoplasms; or
- Recurrent balanitis; or
- Recurrent balanoposthitis; or
- Risk reduction for individuals at high risk of HIV infection; or
- Symptomatic phimosis; or
- Paraphimosis; or
- Tears of the frenulum; or
- Trauma to the foreskin requiring surgical treatment.
Penile circumcision is considered medically necessary when the individual is undergoing surgical repair of congenital urethral or genital abnormalities.
Not Medically Necessary:
Penile circumcision is considered not medically necessary when the criteria listed above have not been met.