# Health insurance question re circumcision

**URL:** <https://boards.straightdope.com/t/health-insurance-question-re-circumcision/750357>\
**Category:** Factual Questions\
**Created:** [March 27, 2016, 2:57pm UTC](https://boards.straightdope.com/t/health-insurance-question-re-circumcision/750357 "2016-03-27T14:57:00Z")\
**Posts on this page:** 2\
**Page:** 3

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**Author:** ![UDS](https://avatars.discourse-cdn.com/v4/letter/u/ecae2f/32.png) [@UDS](https://boards.straightdope.com/u/UDS)\
**Post date:** [March 29, 2016, 4:32am UTC](https://boards.straightdope.com/t/health-insurance-question-re-circumcision/750357/41 "2016-03-29T04:32:23Z")

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> [@alphaboi867](#):
>
> What I meant was does the provider have total freedom in deciding what treatments to perform or do they have to follow guidelines from the provincial health plan (ie the plan will only cover circumcision for diagnosis X & Y, but not Z)? In the US we do have a single-payer insurance for the elderly & disabled (Medicare), but it issues guidelines on everything what what’s covered & when it’s covered to how claims have to be filed (guidelines which many private insurers use as a basis for their own rules when they don’t just copy them outright).

The clinical judgment is a matter for the treating doctor, but he has to operate within the limits of the provincial insurance policy. The insurance policy generally does not cover routine circumcision, but does cover circumcision as a medical necessity, The doctor is free to provide the treatment in any case, but if he wants to claim the cost from the provincial insurer (as opposed to from a private insurer, or from the patient) he has to make (and stand over) the clinical judgment that it’s medically necessary, and he can’t rely on a judgment that it’s routinely medically necessary, since routine circumcision is explicitly not covered; he’s going to have to point to a particular medical necessity in this case.

As to what’s the process if the insurer wants to challenge the treating doctor’s clinical judgment as to medical necessity, or have it reviewed by others, I don’t know. Presumably there is such a process, but I get the impression that Canadian doctors spend a lot less time justifying or defending their clinical judgments to bean-counters than their US counterparts do.

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**Author:** ![puzzlegal](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/puzzlegal/32/3827_2.png) [@puzzlegal](https://boards.straightdope.com/u/puzzlegal)\
**Post date:** [March 29, 2016, 4:46am UTC](https://boards.straightdope.com/t/health-insurance-question-re-circumcision/750357/42 "2016-03-29T04:46:08Z")

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> [@Richard\_Pearse](#):
>
> Circumstances like mine. A foreskin that was tight and made urination very painful (apparently, I was a baby when it happened.)

I once had to get a kitten circumcised for this reason. For complicated reasons, his foreskin had been damaged and it was so tight he couldn’t urinate. Since they had to anesthetize him for the circumcision, they neutered him at the same time (he was to young for a routine neuter). It wasn’t very expensive.

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