54161
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
3.24
Facility
$181.03
Non-Facility
$181.03
Documentation Required
- Documentation of the covered indication/diagnosis that justifies the procedure (one of the listed indications).
- Use of the most appropriate and applicable procedure and diagnosis codes (policy notes that reimbursement is only provided if services are submitted in accordance with relevant criteria, including covered diagnosis and/or procedure code(s)).
- For recurrent UTI: documentation of recurrent UTIs (e.g., culture-proven UTIs) consistent with the National Library of Medicine definition cited in the policy: 'recurrent UTI as two or more UTIs in six months.'
- For VUR: documentation of VUR severity (e.g., imaging/VCUG showing grade 3 or above).
Key Coverage Criteria
- Circumcision in an individual older than 28 days of age (CPT 54161) is considered medically necessary when performed in conjunction with surgical repair of congenital urethral or penile abnormalities.
- Circumcision in an individual older than 28 days of age (CPT 54161) is considered medically necessary for unresponsive or recurrent balanitis, balanoposthitis, or lichen sclerosus.
- Circumcision in an individual older than 28 days of age (CPT 54161) is considered medically necessary for neoplasm of the penis.
- Circumcision in an individual older than 28 days of age (CPT 54161) is considered medically necessary for paraphimosis.
- Circumcision in an individual older than 28 days of age (CPT 54161) is considered medically necessary for severe phimosis or unresponsive or recurrent phimosis.
- Circumcision in an individual older than 28 days of age (CPT 54161) is considered medically necessary for traumatic injury to the foreskin.
2 Active Policies
CIGNA-0582 — Circumcision - (0582)
ANTHEM-CG-SURG-103 — CG-SURG-103 Penile Circumcision
Related Codes
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