CurrentCommunity-CarePolicy N/A

Collagenase (Clostridium histolyticum) injections — Coverage Criteria for Dupuytren's contracture and Peyronie's disease

Clinical coverage criteria and authorization rules for injection of collagenase (clostridium histolyticum) for Dupuytren's contracture and Peyronie's disease for Community-Care members.

Policy Summary

PayerCommunity-Care

PolicyCollagenase injections — Dupuytren's contracture & Peyronie's disease coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization with documentation of the required diagnostic findings and prescriber specialty.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2disease indications listed

3 moauth period Dupuytren's

6 moauth period Peyronie's

J0775HCPCS code listed

Coverage Criteria for Collagenase Injections

Dupuytren's Contracture

Covered when ALL of the following are met

Dupuytren's coverage criteria: Diagnosis of Dupuytren's contracture with a palpable cord

Prescribed by a surgeon or specialist experienced in injection procedures of the hand

Positive tabletop test

Fixed-flexion contracture of the metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joint of 20 degrees or more (excluding the thumb)MCP/PIP contracture >=20 degrees

If approved, authorization allowed for 3 months

Policy Summary

PayerCommunity-Care

PolicyCollagenase injections — Dupuytren's contracture & Peyronie's disease coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization with documentation of the required diagnostic findings and prescriber specialty.

SourceLink

On This Page

If the required diagnostic findings or prescriber specialty are not documented, treatment does not meet the coverage criteria. Examples from the policy include absence of a palpable cord or a positive tabletop test for Dupuytren's contracture, or absence of a palpable plaque and penile curvature ≥ 30 degrees or a non‑urologist prescriber for Peyronie's disease, any of which would render the request non‑covered under these criteria.

Billing and Coding

Applicable HCPCS CodesHCPCSCovered

J0775

Injection, collagenase, clostridium histolyticum, 0.01 mg

Dupuytren's fixed‑flexion contracture threshold

Threshold>= 20 degrees (fixed‑flexion contracture of the MCP or PIP joint)

Anatomic sitesMetacarpophalangeal (MCP) or proximal interphalangeal (PIP) joint; excludes the thumb

Measurement contextContracture must be fixed (permanent bent position) at the time of assessment

Authorization noteIf approved for Dupuytren's, authorization allowed for 3 months

Peyronie's curvature threshold

Threshold>= 30 degrees (curvature deformity at start of therapy)

Required findingPresence of a palpable plaque in addition to curvature

Prescriber requirementPrescribed by a urologist

Authorization noteIf approved for Peyronie's disease, authorization allowed for 6 months

Provider Actions and Authorization

Prior Authorization

Prior Authorization and Authorization Period

Prior authorization is required before service. If approved, authorization periods are: Dupuytren's contracture — 3 months; Peyronie's disease — 6 months. Authorization is subject to benefit changes and must specify the diagnosis and prescribed therapy.

Dupuytren's contracture: 3 months authorization period
Peyronie's disease: 6 months authorization period

Note

Provider Action

Provider must ensure appropriate specialty prescriber when initiating therapy: surgeon or hand-injection specialist for Dupuytren's; urologist for Peyronie's. Verify prior authorization is requested before administration.

Dupuytren's: prescribed by a surgeon or specialist experienced in hand injections
Peyronie's: prescribed by a urologist

Documentation Required

Required Documentation

Document the clinical findings that support the diagnosis and medical necessity: for Dupuytren's — palpable cord, positive tabletop test, and fixed-flexion contracture ≥ 20° of MCP or PIP joint (excluding thumb); for Peyronie's — palpable plaque and curvature deformity ≥ 30° at start of therapy. Include prescriber specialty and measurement details in the medical record.

Dupuytren's required findings: palpable cord; positive tabletop test; fixed-flexion contracture ≥ 20° (MCP or PIP, excluding thumb)
Peyronie's required findings: palpable plaque; curvature deformity ≥ 30° at start of therapy
Include documentation of prescriber specialty and objective measurements

Denial Risk

Denial Triggers

Requests missing the required diagnostic features or lacking the appropriate prescriber specialty are denial risks. Examples: Dupuytren's without a palpable cord or positive tabletop test; Peyronie's without palpable plaque or < 30° curvature; prescriptions from non-specialists when specialty is required.

Denial triggers include absent required diagnostic features (palpable cord, positive tabletop test, palpable plaque, ≥30° curvature)
Denial risk when prescriber is not the required specialist (surgeon/hand specialist for Dupuytren's; urologist for Peyronie's)

Background

Collagenase (clostridium histolyticum) injections are used in this policy to treat two conditions: Dupuytren's contracture and Peyronie's disease. For Dupuytren's the injections are applied when there is a palpable cord with a positive tabletop test and a fixed‑flexion contracture of the MCP or PIP joint of 20 degrees or more (excluding the thumb). For Peyronie's disease the injections are applied when there is a palpable plaque and a curvature deformity of at least 30 degrees at the start of therapy; therapy must be prescribed by a urologist. Authorization durations when approved are 3 months for Dupuytren's and 6 months for Peyronie's disease.

Definitions and Clinical Thresholds

Positive tabletop test

DefinitionInability to place the affected hand flat on a table

UseDiagnostic maneuver for Dupuytren's contracture to document functional impairment

Associated requirementUsed alongside palpable cord and fixed‑flexion contracture >=20° for coverage determination

Fixed‑flexion contracture 60206

DefinitionFixed‑flexion contracture of the MCP or PIP joint of 20 degrees or more (excluding the thumb)

Anatomic exclusionThumb contractures are excluded from this threshold

Coverage contextRequired finding for Dupuytren's coverage when paired with a palpable cord and positive tabletop test

Penile curvature 60306

DefinitionCurvature deformity of at least 30 degrees at the start of therapy

Associated findingMust be accompanied by a palpable plaque for coverage

Prescriber requirementPrescribed by a urologist for Peyronie's disease coverage