Circumcision is the surgical removal of the foreskin of the penis.  This document addresses circumcision when performed alone or in conjunction with an urethrogenital procedure for disease, trauma or structural anomalies.  This document does not address routine circumcisions performed for the term or preterm male infant (generally during initial hospitalization after birth).

Medically Necessary:

Circumcision is considered medically necessary when the individual has ONE or more of the following conditions:

• recurrent balanitis (posthitis); or
• recurrent urinary tract infection; or
• symptomatic phimosis; or
• asymptomatic phimosis in individuals >10 years of age; or
• paraphimosis; or
• genital warts on foreskin (human papilloma virus); or
• preputial neoplasms; or
• tears in the frenulum; or
• trauma to the foreskin.

Circumcision is considered medically necessary when the individual is undergoing surgical repair of congenital urethrogenital defects.

Not Medically Necessary:

Circumcision is considered not medically necessary when the criteria listed above are not met.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Circumcision, in the preterm or term male infant, is an elective routine procedure which this guideline does not address.  However, in some males, a circumcision is performed alone or as part of a procedure to correct urethrogenital problems.

This document is based on a published report on adult circumcision by the American Family Physician (AFP) and the Circumcision Policy Statement of the American Academy of Pediatrics (AAP).  Both resources discuss suggested medical indications for circumcision.  The most frequent indications are phimosis and paraphimosis. Phimosis is a tightness of the foreskin or prepuce that prevents the retraction of the foreskin over the glans and may cause pain with erection or during intercourse.  Conversely, paraphimosis occurs when a narrow foreskin is retracted and becomes trapped behind the groove of the coronal sulcus between the shaft and the glans.  This causes blood to pool in the veins behind the entrapment, leading to swelling and severe pain.  Acute paraphimosis is a urologic emergency requiring reduction of the foreskin through surgical or nonsurgical methods.  Recurrent balanitis and posthitis (inflammation of the foreskin), neoplasms, redundant foreskin tissue and tears in the frenulum are also medical indications for circumcision (AFP, 1999; AAP, 2005).

A circumcision may be performed as part of a surgical repair of congenital urethrogenital defects, most common of which is hypospadias.  Hypospadias is a congenital anomaly resulting in the abnormal location of the urethral opening on the underside of the penis.  Surgical repair of this condition places the urethra at the end of the penis and removes the foreskin if necessary.  The foreskin tissue is sometimes used for grafting if the repair is extensive.

The AFP and AAP recommend that the benefits and risks of circumcision should be explained to the patient or parents of the patient and informed consent obtained (AFP, 1999; AAP, 2005).

Peer Reviewed Publications:

1. Anderson G, Smey P. Current concepts in the management of common urologic problems in infants and children. Pediatric Clinics of North America. 1985; 32(5):1133-1149.
2. Colberg JW. Rudolph's Pediatrics. 21^st ed. New York: McGraw-Hill. 2002. Section 21.16.
3. Fisch M. Concepts for correction of penile hypospadias. Urologe A. 2004; 43(4):402-407.
4. Holman JR, Stuessi KA. Adult circumcision. Am Fam Physician. 1999; 59(6):1514-1518.
5. Schwentner C, Gozzi C, Lunacek A, et al. Interim outcome of the single stage dorsal inlay skin graft for complex hypospadias reoperations. Urol. 2006; 175(5):1872-1876.
6. Tanagho, EA, McAnich JW. Smith's General Urology. 15^th ed. Norwalk: Appleton & Lange. 2000. pg 669.
7. Walsh P, Vaughan ED, Retik A.B, Wein A. Campbell's Urology. 8^th ed. St. Louis: W. B. Saunders Company. 2002. pp 1045-1046.

Government Agency, Medical Society, and Other Authoritative Publications:

1. The American Family Physician. Adult Circumcision. March 15, 1999. Available at: http://www.aafp.org/afp/990315ap/1514.html. Accessed on October 20, 2009.
2. American Academy of Pediatrics (AAP). Task Force on Circumcision: Circumcision Policy Statement. Pediatrics. 1999; 103(3):686-693. Reaffirmed 2005.
3. American Urological Association. Urological Services: Circumcision. May 1989; May 2007 (Revised). Available at: http://www.auanet.org/content/guidelines-and-quality-care/policy-statements/c/circumcision.cfm.  Accessed on October 20, 2009.

Circumcision