Anthem Blue Cross Connecticut CG-SURG-103 Penile Circumcision Form

Effective Date

09/27/2023

Last Reviewed

08/10/2023

Original Document

  Reference



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.