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Anthem Blue Cross ConnecticutCommercial Clinical Policy

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


Penile Circumcision

Indications

(562999) Does the patient have preputial neoplasms? 
(563000) Has the patient had recurrent balanitis? 
(563001) Has the patient had recurrent balanoposthitis? 
(563002) Is the circumcision for risk reduction in a patient at high risk of HIV infection? 
(563003) Does the patient have symptomatic phimosis? 

YesNoN/A
YesNoN/A
YesNoN/A

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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.