CG-SURG-103 Penile Circumcision

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.

Penile circumcision is considered not medically necessary when the criteria listed above have not been met.

The following codes for treatments and procedures applicable to this guideline 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.

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for all other diagnoses not listed, or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.

Elective penile circumcision of an infant in the newborn period is outside the scope of this guideline. Guidelines by American Urological Association (AUA, 2018), American Academy of Family Physicians (AAFP, 2018), and the Centers for Disease Control and Prevention (CDC, 2018) have determined that the health benefits of circumcision in the newborn period are sufficient to justify the procedure for families choosing it. The AUA notes that general anesthesia is generally required for circumcision beyond the newborn period.

There are several conditions that create a medical need for circumcision beyond the newborn period.

Phimosis is the inability to retract the foreskin. This condition can be physiologic or pathologic. The foreskin is a redundant fold protecting the glans penis and urethral meatus. This fold begins developing in the first trimester of pregnancy. By the time of full-term birth, the foreskin is usually fully developed; however, most individuals are born with adhesions between the glans and the inner squamous epithelium of the foreskin. These adhesions prevent full retraction of the foreskin in almost all newborns and prevent full visualization of the urethral meatus in more than half (Baskin, 2005).

Inability to retract the foreskin is normal in most newborns. This condition is known as physiologic phimosis and does not require surgical treatment (McGregor, 2007). Full retraction of the foreskin may not develop until adulthood, but most individuals develop an ability to fully or partially retract the foreskin by their teenage years.

The American Academy of Pediatrics (AAP)/American College of Obstetrics and Gynecologists (ACOG) guidelines for perinatal care (2017) states that, because of physiologic adhesions, the foreskin usually does not retract fully for several years and should not be forcibly retracted. Thus, an unretractable foreskin in a neonate and young infant does not warrant circumcision.

Pathologic phimosis is due to scarring from infection or inflammation. This can lead to inflammation of the glans penis (balanitis) or of the foreskin and glans penis (balanoposthitis). Balanitis and balanoposthitis can be caused by several factors such as bacteria common in urinary tract infections and sexually transmissible pathogens including human papilloma virus (HPV). Balanitis may also be due to a variety of dermatologic conditions including eczema, psoriasis, lichen planus, and lichen sclerosis (Lewis, 2018). Effective treatment of balanitis and balanoposthitis is often provided through treatment of the underlying condition (Anandan, 2018; Celis, 2014; Clouston, 2011).

Paraphimosis occurs when scarring of the foreskin prevents return to its normal position after retraction. This can result in constriction proximal to the glans penis leading to progressive venous and lymphatic engorgement that can develop into arterial constriction over hours to days. Paraphimosis is a urologic emergency requiring urgent reduction of the foreskin (AAFP, 1999; Little, 2005).

Recurrent balanitis, balanoposthitis and paraphimosis are recognized by AUA (AUA 2018) and AAFP (Holman, 1999) as indications for circumcision beyond the neonatal period. A tear of the frenulum impairs or eliminates its function in maintaining normal foreskin position in the unretracted state. Such a tear is recognized by AAFP as an indication for circumcision.

Maternal herpes simplex infection has been proposed as an indication to delay newborn penile circumcision. The AAP and the ACOG guidelines for perinatal care (2017) state:

There are no data indicating that the circumcision of newborn male infants who may have been exposed to herpes simplex virus at birth should be postponed. It may be prudent, however, to delay circumcision for approximately 1 month for those at highest risk of disease (e.g. male infants delivered vaginally by women with active genital lesions).

Circumcision may be performed as part of a surgical repair of congenital urethrogenital defects or after resection of neoplasms of the penis. Hypospadias is a congenital anomaly in which the urethra opens on the underside of the penis. Surgical repair of this condition places the urethra at the end of the penis. Removal of the foreskin is usually necessary to support this procedure.

The use of circumcision as a prophylactic method for HIV infection and other conditions has been shown to be an effective approach in Africa (Iyemosolo, 2021). This has been used as the basis for recommendations for circumcision by the World Health Organization (WHO, 2020). The CDC provides recommendations regarding penile circumcision and prevention of HIV infection and notes the following:

… African-American and Hispanic men have higher risk of HIV infection and lower male circumcision rates than white non-Hispanic males. Similar randomized clinical trials have not been conducted in the United States, but based on evidence from the African trials of the efficacy of male circumcision to prevent HIV transmission, uncircumcised heterosexual men living in areas with high HIV prevalence are likely to experience the most risk-reduction benefit from elective male circumcision.

Corrected Age: Chronologic age reduced by the number of weeks born before 40 weeks gestation.

Frenulum: A band of tissue connecting two other structures. The frenulum of the glans penis connects the foreskin to the glans helping to maintain the position of the foreskin over the glans in the unretracted state.

Phimosis: Constriction of the foreskin which may result in narrowing preventing the foreskin from being retracted.

Paraphimosis: A condition in which the foreskin is retracted and cannot return to its anatomic position. This may lead to swelling, pain, ischemia, and necrosis.

Prepuce: The fold of skin that covers the head of the penis, also a similar fold of skin above the clitoris.

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Subject: Penile Circumcision
Guideline #: CG-SURG-103	Publish Date: 10/01/2024
Status: Revised	Last Review Date: 08/08/2024

CPT
54161	Circumcision, surgical excision other than clamp, device or dorsal slit; older than 28 days of age

ICD-10 Procedure
0VTTXZZ	Resection of prepuce, external approach

ICD-10 Diagnosis
C60.0-C60.9	Malignant neoplasm of penis
D07.4	Carcinoma in situ of penis
D29.0	Benign neoplasm of penis
D40.8	Neoplasm of uncertain behavior of other specified male genital organs
N47.0-N47.8	Disorders of prepuce
N48.0	Leukoplakia of penis
N48.1	Balanitis
Q54.0-Q54.9	Hypospadias
S31.20XA-S31.25XS	Open wound of penis
S38.01XA-S38.01XS	Crushing injury of penis
Z20.6	Contact with and (suspected) exposure to human immunodeficiency virus [HIV]
Z40.8-Z40.9	Encounter for other/unspecified prophylactic surgery

Status	Date	Action
Revised	08/08/2024	Medical Policy & Technology Assessment Committee (MPTAC) review. Revised formatting in the MN statement. Revised References section.
Reviewed	08/10/2023	MPTAC review. Revised Discussion/General Information and References sections.
Reviewed	08/11/2022	MPTAC review. Updated References section.
Revised	08/12/2021	MPTAC review. Modified title, removed Male and replaced with Penile. Modified Clinical Indications to remove Male and replaced with Penile. Updated Discussion/General Information, Definitions, and References sections.
Revised	08/13/2020	MPTAC review. Updated formatting in MN statement. Updated Discussion/General Information and References sections. Reformatted Coding section.
New	08/22/2019	MPTAC review. Initial document development.