Does J0775 require prior authorization?

Yes, J0775 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J0775?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J0775`, Injection, collagenase, clostridium histolyticum, 0.01 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Diagnosis documentation: Dupuytren's contracture with a palpable cord OR Peyronie's disease with a palpable plaque.
Age documentation: Patient is 18 years of age or older.
Objective measurements: For Dupuytren's — documented contracture degree (>=20 degrees for initial therapy; >5 degrees for continuation); for Peyronie's — documented curvature degree (>=30 degrees at start for initial therapy; >=15 degrees remaining for continuation).
Documentation that the flexion deformity results in functional limitations (Dupuytren's).
Provider qualifications: Xiaflex prescribed and administered by a healthcare provider experienced in injection procedures of the hand and in treatment of Dupuytren's contracture (Dupuytren's) or experienced in the treatment of male urological diseases (Peyronie's).
Prior treatment history: Documentation that patient has not received surgical treatment on the selected primary joint within the last 90 days; dates of any recent surgeries; dates of prior Xiaflex treatments (if continuation) and evidence of positive clinical response to prior Xiaflex.

Key Coverage Criteria

Dupuytren's contracture: Xiaflex is proven and medically necessary for the treatment of Dupuytren's contracture when all of the following criteria are met: For initial therapy, all of the following: Patient has diagnosis of Dupuytren's contracture with a palpable cord; and Patient is 18 years of age or older; and Xiaflex is prescribed and administered by a healthcare provider experienced in injection procedures of the hand and in the treatment of Dupuytren's contracture; and Documented contractu [...]
Dupuytren's contracture — continuation of therapy: For continuation of therapy, all of the following: Patient has previously received Xiaflex; and Documentation of positive clinical response to Xiaflex; and Treatment request is for at least one of the following: Metacarpophalangeal (MP) or proximal interphalangeal (PIP) contracture remains in affected cord since previous injection and the contracture is >5 degrees OR A different MP or PIP contracture will be injected and If two injections (two v [...]
Peyronie's disease: Xiaflex is proven and medically necessary for the treatment of Peyronie's disease when all of the following criteria are met: For initial therapy, all of the following: Patient has diagnosis of Peyronie's disease with both of the following: Palpable plaque; and Curvature deformity of greater than or equal to 30 degrees at the start of therapy and Patient is 18 years of age or older; and Xiaflex is prescribed and administered by a healthcare provider experienced in the treatme [...]
Peyronie's disease — continuation of therapy: For continuation of therapy, all of the following: Patient has previously received Xiaflex; and Documentation of positive clinical response to Xiaflex; and Last treatment was at least 6 weeks ago; and Documented curvature deformity of >= 15 degrees remaining since last treatment cycle; and Patient has received less than 4 treatment cycles [i.e., less than 8 injections (2 injections per cycle)]; and Xiaflex dosing is in accordance with the U.S. [...]
FDA indication (informational): "Xiaflex is a combination of bacterial collagenases indicated for the treatment of adult patients with Dupuytren's contracture with a palpable cord and the treatment of adult men with Peyronie's disease with a palpable plaque and curvature deformity of at least 30 degrees at the start of therapy."
Eye (ocular) prostheses and surgical implantation/attachment - considered medically necessary when prosthesis criteria in CPB 0619 - Eye Prosthesis are met.

20 Active Policies

BCBSM-2027130-3301A759A2, XIAFLEX (COLLAGENASE CLOSTRIDIUM HISTOLYTICUM)

BCBSMS-L-5-01-492-D6640BEA0D, Xiaflex (collagenase clostridium histolyticum)

BCBSMS-S-5-01-492-C472F90FE1, State and School Employees' Health Insurance Plan - Xiaflex (collagenase clostridium histolyticum)

HEALTHPARTNERS-CC-AENTRY-045853, Collagenase (Xiaflex)

MULTI

POINT32HEALTH-MDMNG-14381, Xiaflex (collagenase clostridium histolyticum)

MULTI

POINT32HEALTH-PMNG-18091, Xiaflex (collagenase clostridium histolyticum)

MULTI

BCBSNJ-DRUGS-077-36D9E88790, Xiaflex (Collagenase Clostridium Histolyticum)

MODA-XIAFLEX-096786E442, Xiaflex (collagenase)

HEALTHNET_OR-HNOR-COLLAGENASE-CLOSTRIDIUM-HISTOLYTICUM-XIAFLEX-CP-PHAR-82-07BD037FE0, Collagenase Clostridium Histolyticum (Xiaflex); CP.PHAR.82

HIGHMARK_WHOLECARE-HMWC-MEDICAID-MEDICATIO-PTXO9QZMNU6ZRJMULGYKGA-3A35694D20, Xiaflex

IBX-COMMERCIAL-08-01-71-5B3B8A18D9, Collagenase clostridium histolyticum (Xiaflex ), collagenase clostridium histolyticum-aaes (Qwo)

IBX-MEDICARE-ADVANTAGE-MA08-128-2242E9CD40, Collagenase clostridium histolyticum ( Xiaflex ), collagenase clostridium histolyticum-aaes (Qwo)

UHC-EXCH-MD-XIAFLEX-COLLAGENASE-CLOSTRIDIUM-HISTOLYT-BC4112B69D, Xiaflex (Collagenase Clostridium Histolyticum) – Individual Exchange Medical Benefit Drug Policy

UHC-POL-xiaflex, Xiaflex (Collagenase Clostridium Histolyticum)

SUREST-POL-SUREST-xiaflex, Xiaflex (Collagenase Clostridium Histolyticum)

AETNA-CPB-0031, Cosmetic Surgery and Procedures

BCBSIL-RX501.073, Injectable Clostridial Collagenase for Fibroproliferative Disorders

BCBSMT-RX501.073, Injectable Clostridial Collagenase for Fibroproliferative Disorders

BCBSNM-RX501.073, Injectable Clostridial Collagenase for Fibroproliferative Disorders

BCBSOK-RX501.073, Injectable Clostridial Collagenase for Fibroproliferative Disorders

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J0775, Injection, collagenase, clostridium histolyticum, 0.01 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Diagnosis documentation: Dupuytren's contracture with a palpable cord OR Peyronie's disease with a palpable plaque.
Age documentation: Patient is 18 years of age or older.
Objective measurements: For Dupuytren's — documented contracture degree (>=20 degrees for initial therapy; >5 degrees for continuation); for Peyronie's — documented curvature degree (>=30 degrees at start for initial therapy; >=15 degrees remaining for continuation).
Documentation that the flexion deformity results in functional limitations (Dupuytren's).
Provider qualifications: Xiaflex prescribed and administered by a healthcare provider experienced in injection procedures of the hand and in treatment of Dupuytren's contracture (Dupuytren's) or experienced in the treatment of male urological diseases (Peyronie's).
Prior treatment history: Documentation that patient has not received surgical treatment on the selected primary joint within the last 90 days; dates of any recent surgeries; dates of prior Xiaflex treatments (if continuation) and evidence of positive clinical response to prior Xiaflex.

Key Coverage Criteria

Dupuytren's contracture: Xiaflex is proven and medically necessary for the treatment of Dupuytren's contracture when all of the following criteria are met: For initial therapy, all of the following: Patient has diagnosis of Dupuytren's contracture with a palpable cord; and Patient is 18 years of age or older; and Xiaflex is prescribed and administered by a healthcare provider experienced in injection procedures of the hand and in the treatment of Dupuytren's contracture; and Documented contractu [...]
Dupuytren's contracture — continuation of therapy: For continuation of therapy, all of the following: Patient has previously received Xiaflex; and Documentation of positive clinical response to Xiaflex; and Treatment request is for at least one of the following: Metacarpophalangeal (MP) or proximal interphalangeal (PIP) contracture remains in affected cord since previous injection and the contracture is >5 degrees OR A different MP or PIP contracture will be injected and If two injections (two v [...]
Peyronie's disease: Xiaflex is proven and medically necessary for the treatment of Peyronie's disease when all of the following criteria are met: For initial therapy, all of the following: Patient has diagnosis of Peyronie's disease with both of the following: Palpable plaque; and Curvature deformity of greater than or equal to 30 degrees at the start of therapy and Patient is 18 years of age or older; and Xiaflex is prescribed and administered by a healthcare provider experienced in the treatme [...]
Peyronie's disease — continuation of therapy: For continuation of therapy, all of the following: Patient has previously received Xiaflex; and Documentation of positive clinical response to Xiaflex; and Last treatment was at least 6 weeks ago; and Documented curvature deformity of >= 15 degrees remaining since last treatment cycle; and Patient has received less than 4 treatment cycles [i.e., less than 8 injections (2 injections per cycle)]; and Xiaflex dosing is in accordance with the U.S. [...]
FDA indication (informational): "Xiaflex is a combination of bacterial collagenases indicated for the treatment of adult patients with Dupuytren's contracture with a palpable cord and the treatment of adult men with Peyronie's disease with a palpable plaque and curvature deformity of at least 30 degrees at the start of therapy."
Eye (ocular) prostheses and surgical implantation/attachment - considered medically necessary when prosthesis criteria in CPB 0619 - Eye Prosthesis are met.

20 Active Policies

BCBSM-2027130-3301A759A2, XIAFLEX (COLLAGENASE CLOSTRIDIUM HISTOLYTICUM)

BCBSMS-L-5-01-492-D6640BEA0D, Xiaflex (collagenase clostridium histolyticum)

BCBSMS-S-5-01-492-C472F90FE1, State and School Employees' Health Insurance Plan - Xiaflex (collagenase clostridium histolyticum)

HEALTHPARTNERS-CC-AENTRY-045853, Collagenase (Xiaflex)

MULTI

POINT32HEALTH-MDMNG-14381, Xiaflex (collagenase clostridium histolyticum)

MULTI

POINT32HEALTH-PMNG-18091, Xiaflex (collagenase clostridium histolyticum)

MULTI

BCBSNJ-DRUGS-077-36D9E88790, Xiaflex (Collagenase Clostridium Histolyticum)

MODA-XIAFLEX-096786E442, Xiaflex (collagenase)

HEALTHNET_OR-HNOR-COLLAGENASE-CLOSTRIDIUM-HISTOLYTICUM-XIAFLEX-CP-PHAR-82-07BD037FE0, Collagenase Clostridium Histolyticum (Xiaflex); CP.PHAR.82

HIGHMARK_WHOLECARE-HMWC-MEDICAID-MEDICATIO-PTXO9QZMNU6ZRJMULGYKGA-3A35694D20, Xiaflex

IBX-COMMERCIAL-08-01-71-5B3B8A18D9, Collagenase clostridium histolyticum (Xiaflex ), collagenase clostridium histolyticum-aaes (Qwo)

IBX-MEDICARE-ADVANTAGE-MA08-128-2242E9CD40, Collagenase clostridium histolyticum ( Xiaflex ), collagenase clostridium histolyticum-aaes (Qwo)

UHC-EXCH-MD-XIAFLEX-COLLAGENASE-CLOSTRIDIUM-HISTOLYT-BC4112B69D, Xiaflex (Collagenase Clostridium Histolyticum) – Individual Exchange Medical Benefit Drug Policy

UHC-POL-xiaflex, Xiaflex (Collagenase Clostridium Histolyticum)

SUREST-POL-SUREST-xiaflex, Xiaflex (Collagenase Clostridium Histolyticum)

AETNA-CPB-0031, Cosmetic Surgery and Procedures

BCBSIL-RX501.073, Injectable Clostridial Collagenase for Fibroproliferative Disorders

BCBSMT-RX501.073, Injectable Clostridial Collagenase for Fibroproliferative Disorders

BCBSNM-RX501.073, Injectable Clostridial Collagenase for Fibroproliferative Disorders

BCBSOK-RX501.073, Injectable Clostridial Collagenase for Fibroproliferative Disorders

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Ask Backwork about documentation requirements, denial risks, or coverage in your state.

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`J0775`, Injection, collagenase, clostridium histolyticum, 0.01 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0775`, Injection, collagenase, clostridium histolyticum, 0.01 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0775, Injection, collagenase, clostridium histolyticum, 0.01 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0775, Injection, collagenase, clostridium histolyticum, 0.01 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0775`, Injection, collagenase, clostridium histolyticum, 0.01 mg

`J0775`, Injection, collagenase, clostridium histolyticum, 0.01 mg