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Coverage criteria policies

Circumcision - Minnesota Health Care Programs

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Circumcision requires prior authorization.

Coverage

Circumcision is covered when the procedure is medically necessary (in the opinion of the attending physician, a pathologic condition exists where circumcision is required), and is prior authorized.

Indications that are covered

Circumcision is covered for medically necessary reasons, including but not limited to the following indications:

  1. Recurrent urinary tract infections.
  2. Balanitis

Indications that are not covered

Circumcision is not covered for the following reasons, including but not limited to the following:

  1. Routine newborn circumcision not done for a medically necessary reason;
  2. When performed for religious practice;
  3. Phimosis alone is not considered a pathologic condition and does not support medical necessity for circumcision in infants and children.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

54150

Circumcision, using clamp or other device with regional dorsal penile or ring block

54160

Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less)

54161

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

CPT Copyright 2010 American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

  1. Portions of the contents of these coverage criteria relating to Minnesota Public Programs medical coverage criteria are taken directly from the Minnesota Health Care Programs Provider Manual at https://www.revisor.mn.gov/statutes/?id=256B.0625
  2. http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=DHS16_137814
  3. http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=DHS16_179701

References

  1. Barrisford, G. Balanitis and balanoposthitis in adults. In: UpToDate, O’Leary, M (MD, MPH), UpToDate, Waltham, MA. (Accessed on March 13, 2017.)
  2. Hayashi, Y., Kojima, Y., Mizuno, K.,and Kohri, K. (2011) Prepuce: phimosis, paraphimosis, and circumcision.TheScientificWorldJOURNAL: TSW Urology 11, 289–301. DOI 10.1100/tsw.2011.31.
  3. Keheilam,S., Smith,M.,(2016) Indications for Adult circumcision: a contemporary analysis. The Canadian Journal of Urology:23(2),8204-8208
  4. Hooton, T. Acute uncomplicated cystitis and pyelonephritis in men. In: UpToDate, Calderwood, S (MD), UpToDate, Waltham, MA. (Accessed on March 13, 2017).
  5. Rietmeijer, K. Prevention of sexually transmitted infections. In: UpToDate, Calderwood, S (MD), UpToDate, Waltham, MA. (Accessed on March 13, 2017).
  6. Tews, M. Balanoposthitis in children: Epidemiology and pathogenesis. In: UpToDate, Flesher, G (MD), UpToDate, Waltham, MA. (Accessed on March 13, 2017).
  7. Tews, M. Paraphimosis: Clinical manifestations, diagnosis, and treatment. In: UpToDate, Baskin, L (MD, FAAP), UpToDate, Waltham, MA. (Accessed on March 13, 2017).

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Policy activity

  • 01/01/2006 - Date of origin
  • 04/01/2017 - Effective date
Review date
  • 04/2017

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