Asset Publisher
Xiaflex® (collagenase)
Policy Number: PH-0145
Intralesional
Last Review Date: 10/24/2022
Date of Origin: 01/01/2012
Dates Reviewed: 12/2011, 02/2013, 01/2014, 08/2014, 12/2014, 10/2015, 10/2016, 10/2017, 10/2018, 11/2019, 11/2020, 11/2021, 11/2022
FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill. |
- Length of Authorization 1
- Dupuytren’s Contracture: Coverage will be for 3 months and is eligible for renewal for a maximum of 3 injections per joint/cord.
- Peyronie’s Disease: Coverage will be for 6 weeks and is eligible for renewal for a maximum of 4 total treatment cycles for each plaque causing the curvature deformity.
- Dosing Limits
A. Quantity Limit (max daily dose) [NDC Unit]:
- Xiaflex 0.9mg injection: 2 vials per 28 days
B. Max Units (per dose and over time) [HCPCS Unit]:
Dupuytren’s Contracture
- 180 billable units every 28 days
Peyronie’s Disease
- 180 billable units every 42 days
- Initial Approval Criteria 1
Coverage is provided in the following conditions:
- Patient is at least 18 years of age; AND
Dupuytren’s Contracture † Ф 1-3
- Patient has a palpable cord; AND
- Documented flexion contracture of 20° to 100° in a metacarpophalangeal (MP) joint or 20° to 80° in a proximal interphalangeal (PIP) joint; AND
- Documentation of a positive “table top test” defined as the inability to simultaneously place the affected finger(s) and palm flat against a table top; AND
- Documentation that the flexion deformity results in functional limitations
Peyronie’s Disease † Ф 1,4-6
- Prescriber is enrolled in the XIAFLEX REMS Program; AND
- Patient has a palpable plaque on penis; AND
- Patient has stable disease with penis curvature deformity of > 30° and < 90°; AND
- Patient has intact erectile function (with or without use of medications); AND
- Patient does not have isolated hourglass deformity or calcified plaque; AND
- Plaque(s) do not involve the penile urethra; AND
- Will be used in combination with penile modeling procedures; AND
- Patient has not exceeded 4 treatment cycles for each plaque causing the curvature deformity; AND
- Patient has not received a collagenase injection for this condition within the past 6 weeks
† FDA-labeled indication(s); Ф Orphan Drug
- Renewal Criteria 1
Coverage can be renewed based upon the following criteria:
- Patient continues to meet indication-specific relevant criteria identified in section III; AND
Dupuytren’s Contracture
- Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include the following: anaphylaxis and allergic reactions, abnormal coagulation, tendon ruptures or other serious injury to the injected extremity, etc.; AND
- Disease response with treatment as defined by reduction in contracture of the selected primary joint compared to baseline; AND
- Patient has not exceeded 3 injections per joint/cord; AND
- Patient has not received a collagenase injection for this condition within the past 4 weeks
Peyronie’s Disease
- Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include the following: anaphylaxis and allergic reactions, abnormal coagulation, corporal rupture (penile fracture) or other serious injury to the penis, acute post-injection back pain reactions, etc.; AND
- Disease response with treatment as defined by the reduction in curvature of the penis compared to baseline or improvement in Bother domain score of the Peyronie’s Disease Questionnaire (PDQ); AND
- Patient continues to have penis curvature deformity ≥ 15° after previous treatment cycle(s); AND
- Patient has not exceeded 4 total treatment cycles for each plaque causing the curvature deformity; AND
- Patient has not received a collagenase injection for this condition within the past 6 weeks
- Dosage/Administration1
Indication |
Dose |
Dupuytren’s Contracture |
Inject 0.58 mg into each palpable cord with a contracture of a metacarpophalangeal (MP) joint or a proximal interphalangeal (PIP) joint.
|
Peyronie’s Disease |
For each treatment cycle, inject 0.58 mg into the target plaque on a flaccid penis for two injections, separated by 1 to 3 days, according to the injection procedure.
|
- Billing Code/Availability Information
HCPCS Code:
- J0775 – Injection, collagenase, clostridium histolyticum, 0.01 mg: 0.01 mg = 1 billable unit
NDC:
- Xiaflex 0.9 mg powder for injection: 66887-0003-xx
- References
- Xiaflex [package insert]. Malvern, PA; Endo Pharmaceuticals, Inc. August 2022. Accessed September 2022.
- Hurst LC, Badalamente MA, Hentz VR et al. Injectable collagenase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med. 2009; 361:968-79.
- Hurst LC, Badalamente MA, Wang ED. Injectable clostridial collagenase: striving toward non- operative treatment options for fibroproliferative disorders. Available at http://www.aaos.org/research/committee/research/Kappa/KD2009_Hurst.pdf.
- Gelbard M, Goldstein I, Hellstrom WJ, et al. Clinical efficacy, safety and tolerability of collagenase clostridium histolyticum for the treatment of peyronie disease in 2 large double-blind, randomized, placebo controlled phase 3 studies. J Urol. 2013 Jul; 190(1):199-207. doi: 10.1016/j.juro.2013.01.087. Epub 2013 Jan 31.
- Nehra A, Alterowitz R, Culkin DJ, et. al. Peyronie's Disease: AUA Guideline. J Urol. 2015 Sep;194(3):745-53. doi: 10.1016/j.juro.2015.05.098.
- Bella AJ, Lee JC, Grober ED, et al. 2018 Canadian Urological Association guideline for Peyronie’s disease and congenital penile curvature. Can Urol Assoc J. 2018 May; 12(5): E197–E209.
Appendix 1 – Covered Diagnosis Codes
ICD-10 |
ICD-10 Description |
M72.0 |
Palmar fascial fibromatosis [Dupuytren] |
N48.6 |
Induration penis plastica |
Appendix 2 – Centers for Medicare and Medicaid Services (CMS)
Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD), Local Coverage Articles (LCAs), and Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. They can be found at: http://www.cms.gov/medicare-coverage-database/search/advanced-search.aspx. Additional indications may be covered at the discretion of the health plan.
Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCA/LCD): N/A
Medicare Part B Administrative Contractor (MAC) Jurisdictions |
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Jurisdiction |
Applicable State/US Territory |
Contractor |
E (1) |
CA, HI, NV, AS, GU, CNMI |
Noridian Healthcare Solutions, LLC |
F (2 & 3) |
AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ |
Noridian Healthcare Solutions, LLC |
5 |
KS, NE, IA, MO |
Wisconsin Physicians Service Insurance Corp (WPS) |
6 |
MN, WI, IL |
National Government Services, Inc. (NGS) |
H (4 & 7) |
LA, AR, MS, TX, OK, CO, NM |
Novitas Solutions, Inc. |
8 |
MI, IN |
Wisconsin Physicians Service Insurance Corp (WPS) |
N (9) |
FL, PR, VI |
First Coast Service Options, Inc. |
J (10) |
TN, GA, AL |
Palmetto GBA, LLC |
M (11) |
NC, SC, WV, VA (excluding below) |
Palmetto GBA, LLC |
L (12) |
DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA) |
Novitas Solutions, Inc. |
K (13 & 14) |
NY, CT, MA, RI, VT, ME, NH |
National Government Services, Inc. (NGS) |
15 |
KY, OH |
CGS Administrators, LLC |
XIAFLEX® (collagenase) Prior Auth Criteria |
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