Injectable Clostridial Collagenase for Fibroproliferative Disorders

This policy covers injectable clostridial collagenase for fibroproliferative disorders, principally Dupuytren’s contracture (adults with a palpable cord and MP or PIP joint contracture) and Peyronie’s disease (adults with a palpable plaque and objective penile curvature ≥30°), when used consistent with FDA labeling and nationally recognized authoritative references. Coverage is limited to adult patients, requires dosing/frequency/duration consistent with standard compendia or peer‑reviewed evidence, is subject to procedural limits (e.g., treatment of up to 2 cords/joints per visit, finger extension 24–72 hours post‑injection, up to 3 injections per cord separated by ~4 weeks, and for Peyronie’s up to 4 cycles with 2 injections plus one modeling procedure per cycle), excludes uses lacking evidence (including adhesive capsulitis), and remains subject to the member’s benefit plan and applicable state rules (Ohio has specific off‑label criteria).

"Therapies are covered only when proven effective for the relevant diagnosis or procedure."