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

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.