Circumcision - Medical Necessity Criteria
Criteria for documenting medical necessity of circumcision for both children and adults
Contents:
- What is circumcision?
- When is circumcision medically necessary?
- Medical necessity criteria for circumcision
- FAQs
- Is circumcision covered by insurance?
- Does Medicaid cover circumcision?
- Documentation to submit
- Health plan criteria for circumcision and other references
What is circumcision?
Circumcision is the surgical removal of the foreskin, the hood of skin that covers the tip of the penis.
It is usually done during childhood, although adults may also undergo circumcision.
When is circumcision medically necessary?
Circumcision is generally considered medically necessary when the person has a medical condition that would be resolved or improved by circumcision.
There is only a limited number of such conditions and the decision as to what particular conditions they will cover circumcision for is made by individual health plans. To be covered by insurance, the medical necessity criteria of the patient’s health plan must be fulfilled.
Circumcision is generally not considered medically necessary when done as a routine procedure or for religious/ritual purposes.
Medical necessity criteria for circumcision
Generally, circumcision may be considered medically necessary for patients who have:
- Balanitis, when it is recurrent
- Balanoposthitis, when it is recurrent
- Chordee
- Condyloma acuminatum
- Congenital urethral or genital abnormalities, for which they will undergo surgical repair
- Dyspareunia
- Frenulum tears
- High risk of HIV infection, for risk reduction
- Neurogenic bladder (in newborns)
- Paraphimosis
- Penile cancer being treated with radiation therapy
- Phimosis, only when it is symptomatic (phimosis by itself is not considered a medically necessary indication for circumcision)
- Preputial adhesions causing non-retractile foreskin
- Preputial neoplasms
- Spina bifida (in newborns)
- Trauma to the foreskin that requires surgical treatment
- Urinary tract infections, when they are recurrent
- Vesicoureteral reflux, at least Grade III
Some health plans require that conservative treatment must have been tried and found to be inadequate before circumcision can be considered medically necessary.
Note: not all of these conditions are considered medically necessary indications for circumcision by all health plans. Verify with patient’s own health plan for which conditions they cover circumcision.
FAQs
Is circumcision covered by insurance?
Most health plans cover circumcision when it is medically necessary.
Some plans also pay, at least partially, for circumcision even when this is not medically necessary. For example:
- UnitedHealthcare West (California) covers circumcision for male newborns when the procedure is performed at the hospital prior to discharge.
- Tricare covers circumcision performed during the child’s first 30 days; after 30 days, it is covered only when medically necessary.
- Community Health Plan of Washington covers up to $200 in circumcision costs per child when the procedure is not medically necessary.
Does Medicaid cover circumcision?
Medicaid covers circumcision when it is medically necessary.
Routine circumcision is usually not covered, nor is it covered when done only for religious or ritual reasons.
Documentation to submit
These are the things you can prepare documentation of in order to support your statement that circumcision is medically necessary. Submit only those that apply.
Documentation of a medical condition for which circumcision may be medically necessary:
Documentation of any conservative treatments already done or given to the patient, including but not limited to:
Health plan criteria for circumcision and other references
- American Academy of Pediatrics Circumcision Policy Statement
- Amerigroup Clinical UM Guideline on Penile Circumcision
- Anthem Blue Cross Clinical UM Guideline on Penile Circumcision
- Community Health Plan of Washington Benefit Policy on Circumcision
- Healthy Blue BlueChoice HealthPlan of South Carolina Clinical UM Guideline on Penile Circumcision
- Johns Hopkins Medicine Explainer on Circumcision
- Mississippi Medicaid Policy on Circumcision
- North Carolina Medicaid Clinical Coverage Policy for Circumcision
- Texas Children’s Health Plan Circumcision Guidelines
- Tricare Policy on Circumcision (Newborn)
- UCare Coverage Policy on Male Circumcision
- UnitedHealthcare West (California) Benefit Interpretation Policy on Maternity and Newborn Care
- UnitedHealthcare West (Oklahoma, Oregon, Texas, Washington) Benefit Interpretation Policy on Maternity and Newborn Care