CommercialPrior AuthMedium impact
Collagenase Clostridium Histolyticum (Xiaflex) (CPB 1061, reviewed 2026-09-14)
Aetna·Plastic Surgery, Orthopedics, Urology·Medical Policy
We identified it
Sep 30, 2026
Summary
Aetna's Xiaflex (collagenase clostridium histolyticum) policy establishes coverage criteria for two FDA-approved indications: Dupuytren's contracture and Peyronie's disease. Billing teams must verify that patients meet specific clinical criteria (contracture degree, positive tabletop test, plaque characteristics, age 18+) before authorization. All other uses are considered experimental and non-covered.
Action Required
Immediately: Billing team must implement prior authorization process for Xiaflex (J0775) claims. For Dupuytren's contracture: verify presence of palpable cord, contracture ≥20 degrees, positive tabletop test, patient age ≥18, and maximum 3 injections per cord at 4-week intervals. For Peyronie's disease: verify stable disease ≥3 months, palpable plaque with curvature 30-90 degrees, intact erectile function, patient age ≥18, and lifetime maximum 8 injections total. Reject claims for cosmetic use (e.g., cellulite), ultrasound-guided injections, or hand therapy post-treatment. Update billing system to flag any indication other than M72.0 (Dupuytren's) or N48.6 (Peyronie's) as experimental/non-covered. Confirm prescriber credentials: hand surgery specialists for Dupuytren's; urologists with XIAFLEX REMS program completion for Peyronie's. Document all authorization criteria in claim notes. Deny claims without proper clinical documentation. Route denials to providers with specific guidance on coverage requirements.