Clinical Policy 1A-22, Medically Necessary Circumcision Revised

Tuesday, December 29, 2020

Clinical Coverage Policy 1A-22, Medically Necessary Circumcision, has been revised and will post with an effective date of Jan. 1, 2021 on the NC Medicaid website.

A preponderance of high-quality evidence shows the health benefits of newborn male circumcision outweigh the risks of the procedure and could be considered medically necessary in certain circumstances. The health benefits of circumcision include lower risks of acquiring Human Immunodeficiency Virus (HIV), genital herpes, human papilloma virus (HPV) and syphilis.  Circumcision also lowers the risk of penile cancer over a lifetime, reduces the risk of cervical cancer in sexual partners and lowers the risk of urinary tract infections in the first year of life. The American Academy of Pediatrics (AAP) endorses male circumcision, though it does not currently recommend routine circumcision for all male newborns. The AAP leaves the circumcision decision up to parents and supports use of anesthetics for infants who have the procedure.

In addition to circumcisions performed to lower the risk of acquiring HIV, medical necessity for newborn circumcisions has been updated to include the following:

  • Congenital obstructive urinary tract anomalies
  • Neurogenic bladder
  • Spina bifida
  • Urinary tract infections

In addition to circumcisions performed to lower the risk of acquiring HIV, medical necessity for non-newborn circumcisions has been updated to include the following:

  • A documented prior history of recurrent urinary tract infections
  • Documented vesicoureteral reflux of at least a Grade III
  • Paraphimosis
  • Recurrent balanoposthitis
  • Recurrent balanitis or balanitis xerotica obliterans
  • Congenital chordee
  • True phimosis causing urinary obstruction, hematuria or preputial pain for a beneficiary age six and older
  • Secondary or acquired phimosis causing urinary obstruction, hematuria or preputial pain unresponsive to medical therapy
  • Condyloma acuminatum
  • Malignant neoplasm of the prepuce

Effective Jan. 1, 2021, providers billing for medically necessary circumcisions performed for the prevention of disease for newborn and non-newborn male beneficiaries should submit diagnosis Z29.8 (encounter of other specified prophylactic measures) and an appropriate circumcision procedure code.

Providers are encouraged to review Clinical Policy 1A-22, Medically Necessary Circumcision for other general language and formatting updates.

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NCTracks Contact Center: 800-688-6696