Medical Policy Updates

Notification of Policy Revisions Effective April 6, 2021 (Posted February 9, 2021)

Medical Policy Revision
Injectable Clostridial Collagenase for Fibroproliferative Disorders "Notification" Clarification added around dosing and administration for Peyronie’s disease. Edits made throughout policy for clarity. Added the following to “When Covered” section: “initial authorization will be limited to two treatment cycles, each cycle consisting of two Xiaflex injections and a penile modeling procedure. Subsequent authorization(s) for third and fourth treatment cycles may be given if the penile curvature deformity remains at greater than 15 degrees after the second treatment cycle.” Added the following to “When Not Covered” section: “Retreatment of the same penile plaque after a completed course of injectable clostridial collagenase for the treatment of Peyronie’s disease is considered investigational.” References added. Medical Director review 2/2021. Policy notification given 2/9/2021 for effective date 4/6/2021.