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    v1.0.28
    OpenPayerPolicy UpdatesUrologyCommunity-Care collagenase injections Coverage | O…
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    CurrentCommunity-CarePolicy N/A

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

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    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
    Last ReviewJun 1, 2023
    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
    J0775

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    HCPCS 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

    Peyronie's Disease

    Covered when ALL of the following are met

    Peyronie's coverage criteria: Diagnosis of Peyronie's disease with a palpable plaque
    Curvature deformity of at least 30 degrees at the start of therapyCurvature >=30 degrees
    Prescribed by a urologist

    If approved, authorization allowed for 6 months

    None beyond the specific diagnostic and prescriber requirements are listed in the policy. Coverage is defined by meeting the stated clinical findings and provider qualifications for each indication rather than by additional exclusionary criteria.

    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
    J0775Injection, 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 finding

    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

    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 context
    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
    Last ReviewJun 1, 2023
    Next Review DateN/A
    Key ActionObtain prior authorization with documentation of the required diagnostic findings and prescriber specialty.
    SourceLink
    On This Page
    Coverage Criteria for Collagenase InjectionsBilling and CodingProvider Actions and AuthorizationBackgroundDefinitions and Clinical Thresholds
    Presence 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
    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)
    Required 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