Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Treatment of Dupuytren's Contracture
Collagenase clostridium histolyticum (Xiaflex) may be considered medically necessary for the treatment of Dupuytren's contracture when the following are met:
- Injection of collagenase clostridium histolyticum (Xiaflex) into a palpable Dupuytren's cord with a contracture of a metacarpophalangeal (MP) joint or a proximal interphalangeal (PIP) joint; and
- No more than two joints in the same hand may be treated with collagenase clostridium histolyticum (Xiaflex) during a treatment visit; and
- Approximately 24 to 72 hours following an injection, perform a finger extension procedure if a contracture persists; and
- Injections and finger extension procedures may be administered up to three (3) times per cord at approximately four (4)-week intervals; and
- Inject up to two cords in the same hand at a treatment visit. If an individual has other cords with contractures, inject those cords at another treatment visit.
Note: *Collagenase clostridium histolyticum (Xiaflex) injections for Dupuytren's contracture should be administered by a healthcare provider experienced in injection procedures of the hand and certified in the *Xiaflex Risk Evaluation and Mitigation Strategy (REMS) Program.
Collagenase clostridium histolyticum (Xiaflex) and related procedures is considered experimental/investigational for all other indications and therefore non-covered. Scientific evidence does not support its use for any other indications.