Mountain State Medical Policy Bulletin

Section: Injections
Number: I-107
Topic: Injectable Collagenase Clostridium Histolyticum (Xiaflex™)
Effective Date: January 1, 2011
Issued Date: January 3, 2011
Date Last Reviewed: 10/2010

General Policy Guidelines

Indications and Limitations of Coverage

Coverage for collagenase clostridium histolyticum (Xiaflex™) is determined according to individual or group customer benefits. Collagenase clostridium histolyticum is indicated for the treatment of adult patients with Dupuytren's contracture with a palpable cord.

Treatment of Dupuytren's contracture consists of an injection of 0.58 mg collagenase into a palpable Dupuytren's cord with a contracture of a metacarpophalangeal (MP) joint or a proximal interphalangeal (PIP) joint followed approximately 24 hours after the injection by manipulation of the finger if contracture persists. Injections and finger extension procedures may be administered up to 3 times per cord at approximately 4-week intervals.

The use of collagenase clostridium histolyticum for any other indication is considered experimental/investigational, and therefore not covered. A participating, preferred, or network provider can bill the member for the non-covered service.

Collagenase clostridium histolyticum is not reimbursable under the prescription drug benefit

Description

Collagenases are enzymes that digest native collagen. Clostridial collagenase is a bacterial collagenase derived from clostridium histolyticum. Treatment of Dupuytren's contracture consists of an injection of collagenase into the cord followed by manipulation of the finger if contracture persists. Injection may be done up to 3 times at 4-week intervals.

Dupuytren's disease is a benign fibroproliferative condition characterized by excessive collagen deposition causing abnormal thickening of the fascia. This results in the formation of a ropelike cord beneath the skin of the palm, stretching from the palm into the fingers. Gradually, the progression of these cords may cause the fingers to bend into the palm resulting in permanent joint contractures. Xiaflex is the first FDA-approved nonsurgical option for the treatment of adult patients with Dupuytren's contracture with a palpable cord. 


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

J0775     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient's condition.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

Badalamente MA, Hurst LC. Efficacy and safety of injectable mixed collagenase subtypes in the treatment of Dupuytren's contracture. J Hand Surg. 2007;32A:767-774.

Hurst LC, Badalamente MA, Hentz VR, et al. Injectable collagenase clostridium histolyticum for Dupuytren's contracture. N Engl J Med. 2009;361(10):968-79.

Xiaflex™ (collagenase clostridium histolyticum)[package insert]. Malvern, PA:Auxilium Pharmaceuticals, Inc. 02/2010.

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Diagnosis Codes

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Glossary





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.