Xiaflex requires prior authorization from HealthPartners Pharmacy Administration.
Xiaflex is generally covered for treating Dupuytren's contractures involving 1 or 2 joints.
Xiaflex is indicated for the treatment of adult patients with Dupuytren’s contracture with a palpable cord.
Xiaflex contains collagenase clostridium histolyticum which lyses collagen. Injection into a Dupuytren’s cord may lead to a disruption of contracted cords and improved function.
Dupuytren’s contracture is characterized by progressive fibrosis of tissue in the palms. Joint stiffness and a loss of flexibility can develop, with contractures drawing fingers into a contracted position.
If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.
J0775 – Injection, collagenase, clostridium histolyticum, 0.01 mg
66887000301 – 0.9 mg single dose vial
CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
- Xiaflex prescribing information. Auxilium Pharmaceuticals, Inc. February 2012.
- Injectable collagenase clostridium histolyticum for Dupuytren's contracture. Hurst LC, Badalamente MA, Hentz VR, Hotchkiss RN, Kaplan FT, Meals RA, Smith TM, Rodzvilla J; CORD I Study Group. N Engl J Med. 2009 Sep 3;361(10):968-79.
This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.