Collagenase clostridium histolyticum (Xiaflex)
EVICORE-MEDICAL_DRUG-AEAAFBAE
Xiaflex is covered only for the FDA‑approved indications: adult Dupuytren's contracture with a palpable cord and ≥20° MP/PIP contracture, and adult men with Peyronie's disease with a palpable plaque and ≥30° curvature (or ≥15° if previously treated); off‑label uses are excluded. Coverage requires age ≥18, administration by an experienced provider, documentation of baseline severity/palpable lesion and prior Xiaflex history, adherence to dosing limits (0.58 mg per injection; Dupuytren's max 3 injections per cord and ≤2 cords per visit with ≥4 weeks between doses per cord; Peyronie's max 4 cycles/8 injections per course with paired injections 1–3 days apart and ~6 weeks between cycles), and specified approval durations (Dupuytren's 3 months, Peyronie's 6 months).
"Xiaflex is indicated for the treatment adult patients with Dupuytren's contracture with palpable cord."