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HealthPartners

Coverage criteria policies

Collagenase (Xiaflex®)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Xiaflex requires prior authorization from HealthPartners Pharmacy Administration.

Coverage

Dupuytren’s contracture

Xiaflex is generally covered when ALL the following criteria are met:

  1. Documented diagnosis of Dupuytren’s contracture with a palpable cord of at least one finger (other than the thumb) involving the metacarpophalangeal joint or the proximal interphalangeal joint; AND,
  2. The patient has a positive “table top test” (defined as the inability to simultaneously place the affected finger and palm flat against a tabletop; AND,
  3. Documentation that the flexion deformity results in functional limitations.

Approvals will be given for six months and a maximum of 3 injections per cord.

Peyronie’s disease

Xiaflex is generally covered when ALL the following criteria are met:

  1. The prescriber is a urologist or otherwise experienced in the treatment of male urological diseases; AND
  2. Patient is 18 years of age or older and has intact erectile function with or without the use of medications; AND
  3. Documented diagnoses of Peyronie’s disease with a palpable plaque; AND
  4. Curvature deformity is at least 30 degrees at the start of therapy.

For each plaque causing the curvature deformity, up to four treatment cycles may be approved (maximum of 8 injection procedures and 4 modeling procedures).

Definitions

XIAFLEX is a combination of bacterial collagenases indicated for:

  • The treatment of adult patients with Dupuytren’s contracture with a palpable cord
  • 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

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.

HCPCS Code

Codes

Description

J0775

Injection, collagenase, clostridium histolyticum, 0.01 mg

NDC Codes

Codes

Description

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.

Products

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.

References

  1. Xiaflex prescribing information. Auxilium Pharmaceuticals, Inc. August, 2016.
  2. 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.
  3. Peyronie’s disease: AUA guideline. Nehra A, Alterowitz R, Dulkin DJ, et al., https://www.auanet.org/education/guidelines/peyronies-disease.cfm (Accessed 10/22/2015).

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Policy activity

  • 07/30/2010 - Date of origin
  • 07/30/2010 - Effective date
Review date
  • 11/2016

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