Circumcision denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an male enrollee has requested authorization and coverage for circumcision for treatment of the enrollee, who presented for circumcision. Findings: The physician reviewer found that the American Academy of Pediatrics (AAP) recently published a policy statement regarding circumcision, supporting the procedure. The AAP has determined that the benefits of circumcision outweigh the risk, recommending circumcision for any neonatal infant in whom there are no medical contraindications, accept for family preference. The Center for Disease Control (CDC) has taken this stance even further, recommending discussion with adolescent and adult men regarding benefits and risks of circumcision surgery.

The patient is a 10-month-old male whose parents wished him to be circumcised in the neonatal period. However, he had medical problems including aspiration pneumonia and gastroesophageal reflux requiring hospitalization for medical treatment in the neonatal intensive care unit. He could not have a circumcision then and for some time afterwards due to his medical condition. He has by now recovered from those medical problems well enough to undergo circumcision, and the parents wish to have it performed. The patient’s primary care physician referred the patient to an urologist and the patient’s parents have consulted with the urologist for the purpose of having their child circumcised.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient is with a diagnosis of physiologic phimosis. On 6/29/17, the records noted the presence of smegma under the foreskin. The records noted no issues with urination. Consultation dated 1/28/19 reported the patient had no voiding problems and had no infections. The provider reported the distal foreskin was tight with phimosis. The provider is recommending a circumcision. On 3/12/19, the parents reported that they noticed blood and irritation on the penis. The parents did not report that the patient had issues with urinating. The provider recommended following up with urology and nystatin-triamcinolone cream. The patient’s parent has requested authorization and coverage for circumcision. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for circumcision. On a visit with the urologist, the enrollee indicated he wanted a circumcision due to irritation from pubic hair. He denied issues with urinating or sexual intercourse and stated he desired to keep his pubic hair instead of shaving. On examination, the urologist documented easily retractable foreskin and normal genitalia. He did not recommend circumcision; however, the enrollee wanted the surgery. Complications were discussed with the enrollee and the procedure was scheduled.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Circumcision, then check the rights and deadlines that apply to your plan.