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Injectable Clostridial Collagenase for Fibroproliferative Disorders

Injectable clostridial collagenase for the treatment of Dupuytren’s contracture in adults with a palpable cord may be considered medically necessary, for up to 3 injections at intervals of at least 30 days (see the Policy Guidelines section).
Injectable clostridial collagenase for the treatment of Peyronie’s disease in adults may be considered medically necessary for a maximum of 4 treatment cycles when the following criteria are met:

Patient has a diagnosis of Peyronie’s disease with a palpable plaque; AND patient has a curvature deformity of at least 30 degrees at the start of therapy; AND the injections will be used in combination with a penile modeling procedure (1 to 3 days after injection).

Injectable clostridial collagenase is considered investigational for all other indications including, but not limited to, adhesive capsulitis.

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