Xiaflex - BMC HealthNet Plan

http://www.dupuytrenfoundation.org/DupPDFs/2009_FDA.pdf Accessed April14, 20103. Robert P Sheon, MD, Bruce C Anderson, MD. Dupuytren’s Contracture. Up toDate online. Accessed April 14, 2010.4. Ghazi M. Rayan, MD. Dupuytren Disease: Anatomy, Pathology, Presentation,and Treatment. The Journal of Bone and Joint Surgery (American). 2007;89:189-198. Accessed April 14, 2010.5. Lawrence C. Hurst, M.D., etc. Injectable Collagenase Clostridium Histolyticumfor Dupuytren's Contracture. The New England Journal of Medicine. 2009;Volume 361:968-979Policy History:Effective Date: 05/13/2010Date of Review/Revision05/12/2011 – P&T Annual Review, no changes required07/14/2011 – policy applied to Commercial03/08/2012 – P&T Annual Review, no changes requiredLast Review Date: 03/14/2013 – P&T annual review, no changes requiredNext Review Date: 03/13/2014Approval DatesRegulatory Approval: N/AInternal Approval:Initial approval by Pharmacy & Therapeutics Committee – 05/13/2010Authorizing entityN/AIMPORTANT NOTES:‣ Not all services are covered for all products or employer groups. This medical policyexpresses the Plan's determination of whether certain services or supplies are medicallynecessary, experimental or investigational or cosmetic. The Plan has reached theseconclusions based upon the regulatory status of the technology and a review of clinicalstudies published in peer-reviewed medical literature. Even though this policy mayThis guideline provides information on BMC HealthNet Plan clinical criteria and claims adjudication processing guidelines. Theuse of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement isbased on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Planpolicies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider.Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the mostrecent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accreditingorganization guidelines and requirements, including NCQA.This document is subject to further revision in response to additional terms and requirements imposed under the Integrated CareProgram, including the ICP contract.BMCHP refers to Boston Medical Center HealthNet Plan in Massachusetts and Well Sense Health Plan in New Hampshire.Boston Medical Center HealthNet Plan and Well Sense Health Plan are trade names used by Boston Medical Center Health Plan,Inc.BMC HealthNet Plan – Xiaflex4 of 5