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:
Individual has a diagnosis of Peyronie’s disease with a palpable plaque; AND individual 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.
