CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria: Radiation Therapy for Palmar Fibromatosis (Dupuytren's Contracture)

Clinical review criteria for the use of radiation therapy to treat Dupuytren's contracture (palmar fibromatosis) for Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. Applies to plan medical necessity determinations for Medicare and non‑Medicare members as described.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria: Radiation Therapy for Palmar Fibromatosis (Dupuytren's Contracture)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionApply these KPWA Clinical Review Criteria when making medical necessity decisions and verify authorization requirements via the Pre-authorization Code Check for specific codes and plan types.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

InsufficientMTAC conclusion on effectiveness and safety

30 Gy, 21 GyRadiation regimens evaluated in RCT

M72.0Primary diagnosis code listed

77401, 77412Procedure codes listed as not medically necessary

Medical Necessity Determination

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Medical Necessity Conclusion Note: Last reviewed 2024-04-17

Kaiser MTAC assessment and coverage determination:

ALL of the following

The use of radiotherapy for Dupuytren's contracture does not meet Kaiser Permanente Medical Technology Assessment Criteria due to insufficient evidence for effectiveness and safety.

Medicare determination note

For Medicare members:

ALL of the following

No applicable CMS NCD, LCD, or Local Coverage Article; KPWA uses the Non-Medicare criteria for medical necessity determinations.

Relevant Diagnosis and Procedure Codes

Considered Not Medically Necessary - CPT/HCPCSmixedNot Covered

77401	Radiation treatment delivery, superficial and/or orthovoltage, per day (listed as not medically necessary for Dupuytren's contracture)
77412	Radiation treatment delivery, > or = 2 MeV; complex (listed as not medically necessary for Dupuytren's contracture)

Relevant ICD-10 DiagnosisICD-10Not Covered

M72.0

Palmar fascial fibromatosis [Dupuytren]

Authorization & Documentation Guidance

Documentation Required

Use Clinical Review Criteria for coverage determinations

Providers and reviewers must apply these KPWA Clinical Review Criteria for medical necessity decisions for KPWA members; consult the member's Evidence of Coverage or KPWA Member Services to determine benefits for a specific member.

Prior Authorization

Authorization check reminder

Verify authorization requirements for a specific code and plan type using the Pre-authorization Code Check; the document notes code-specific verification is required.

77401
77412

Clinical and Evidence Context

Dupuytren's contracture is a benign fibrotic disorder of the palmar fascia characterized by thickening of connective tissue in the palm with development of nodules and cords that can lead to progressive finger contracture. Symptoms often progress slowly and may be bilateral; presentation is typically in middle age and the condition can be associated with factors such as family history, diabetes, smoking, alcohol use, trauma and certain medications. Treatment options focus on managing disability and preventing progression and range from conservative measures (stretching, splinting) to injections and surgical fasciectomy.

Radiotherapy (RT) has been used as a non-surgical option in early-stage disease with the intent of halting or slowing progression by targeting affected nodules and cords using superficial X-rays or electron beams delivered over several visits. Published reports include mostly nonrandomized case series and one randomized trial that compared two RT dose schedules (30 Gy versus 21 Gy). Some studies reported symptom regression and high patient satisfaction, and acute and chronic local skin effects were the most commonly reported adverse events.

However, the Kaiser Permanente Medical Technology Assessment Committee (MTAC) found the overall evidence to be limited, heterogeneous, and methodologically weak. Key limitations across the literature include lack of adequate comparator groups (no trials comparing RT with standard non‑radiation treatments or sham therapy), heterogeneous dosing regimens, inclusion of patients who had prior treatments, and limited long‑term safety data with only one study providing extended follow‑up. For these reasons MTAC concluded there is insufficient evidence to demonstrate RT’s effectiveness or to fully characterize its long‑term safety for Dupuytren's contracture.

Document History

2024-04-17Last review / revisionLatest

Policy last revised on 2024-04-17 as part of ongoing MPC reviews; MTAC previously concluded there is insufficient evidence to support the effectiveness or safety of radiotherapy for Dupuytren's contracture.

2014-10-28Initial review / coding note

Initial document review and coding entries recorded (codes 77401, 77412, and diagnosis M72.0 listed as considered not medically necessary).

2019-12-24Revision history entry

Document includes a revision history entry dated 2019-12-24.