J0775, Injection, collagenase, clostridium histolyticum, 0.01 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Diagnosis documentation: Dupuytren's contracture with a palpable cord OR Peyronie's disease with a palpable plaque.
- Age documentation: Patient is 18 years of age or older.
- Objective measurements: For Dupuytren's — documented contracture degree (>=20 degrees for initial therapy; >5 degrees for continuation); for Peyronie's — documented curvature degree (>=30 degrees at start for initial therapy; >=15 degrees remaining for continuation).
- Documentation that the flexion deformity results in functional limitations (Dupuytren's).
Key Coverage Criteria
- Dupuytren's contracture: Xiaflex is proven and medically necessary for the treatment of Dupuytren's contracture when all of the following criteria are met: For initial therapy, all of the following: Patient has diagnosis of Dupuytren's contracture with a palpable cord; and Patient is 18 years of age or older; and Xiaflex is prescribed and administered by a healthcare provider experienced in injection procedures of the hand and in the treatment of Dupuytren's contracture; and Documented contractu [...]
- Dupuytren's contracture — continuation of therapy: For continuation of therapy, all of the following: Patient has previously received Xiaflex; and Documentation of positive clinical response to Xiaflex; and Treatment request is for at least one of the following: Metacarpophalangeal (MP) or proximal interphalangeal (PIP) contracture remains in affected cord since previous injection and the contracture is >5 degrees OR A different MP or PIP contracture will be injected and If two injections (two v [...]
- Peyronie's disease: Xiaflex is proven and medically necessary for the treatment of Peyronie's disease when all of the following criteria are met: For initial therapy, all of the following: Patient has diagnosis of Peyronie's disease with both of the following: Palpable plaque; and Curvature deformity of greater than or equal to 30 degrees at the start of therapy and Patient is 18 years of age or older; and Xiaflex is prescribed and administered by a healthcare provider experienced in the treatme [...]
- Peyronie's disease — continuation of therapy: For continuation of therapy, all of the following: Patient has previously received Xiaflex; and Documentation of positive clinical response to Xiaflex; and Last treatment was at least 6 weeks ago; and Documented curvature deformity of >= 15 degrees remaining since last treatment cycle; and Patient has received less than 4 treatment cycles [i.e., less than 8 injections (2 injections per cycle)]; and Xiaflex dosing is in accordance with the U.S. [...]
- FDA indication (informational): "Xiaflex is a combination of bacterial collagenases indicated for the treatment of adult patients with Dupuytren's contracture with a palpable cord and the treatment of adult men with Peyronie's disease with a palpable plaque and curvature deformity of at least 30 degrees at the start of therapy."
- Eye (ocular) prostheses and surgical implantation/attachment - considered medically necessary when prosthesis criteria in CPB 0619 - Eye Prosthesis are met.
8 Active Policies
UHC-POL-xiaflex, Xiaflex (Collagenase Clostridium Histolyticum)
AETNA-CPB-0031, Cosmetic Surgery and Procedures
BCBSIL-RX501.073, Injectable Clostridial Collagenase for Fibroproliferative Disorders
BCBSMT-RX501.073, Injectable Clostridial Collagenase for Fibroproliferative Disorders
BCBSNM-RX501.073, Injectable Clostridial Collagenase for Fibroproliferative Disorders
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