Clinical UM Guideline
|Subject:||Surgical Treatment for Dupuytren's Contracture|
|Guideline #:||CG-SURG-11||Current Effective Date:||10/14/2014|
|Status:||Reviewed||Last Review Date:||08/14/2014|
This document addresses surgical treatments for Dupuytren's contracture. Dupuytren's contracture is a painless thickening and fixed tightening (contracture) of the tissue beneath the skin on the palm of the hand and fingers. Progressive contracture may result in deformity and loss of function of the hand.
Note: Please see the following related document(s) for additional information:
Surgical treatment for Dupuytren's contracture is considered medically necessary when a palpable palmar cord has been documented to impair the individual's functional activities AND any of the following:
Not Medically Necessary:
Surgical treatment for Dupuytren's contracture is considered not medically necessary when the criteria above are not met.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|26040||Fasciotomy, palmar (eg, Dupuytren's contracture); percutaneous|
|26045||Fasciotomy, palmar (eg, Dupuytren's contracture); open, partial|
|ICD-9 Procedure||[For dates of service prior to 10/01/2015]|
|82.35||Other fasciectomy of hand|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|728.6||Contracture of palmar fascia|
|ICD-10 Procedure||[For dates of service on or after 10/01/2015]|
|0MN70ZZ||Release right hand bursa and ligament, open approach|
|0MN73ZZ||Release right hand bursa and ligament, percutaneous approach|
|0MN74ZZ||Release right hand bursa and ligament, percutaneous endoscopic approach|
|0MN80ZZ||Release left hand bursa and ligament, open approach|
|0MN83ZZ||Release left hand bursa and ligament, percutaneous approach|
|0MN84ZZ||Release left hand bursa and ligament, percutaneous endoscopic approach|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
|M72.0||Contracture of palmar fascia|
Dupuytren's contracture is a multifactorial disease meaning that several causes have been associated with the development of the disease, but a single cause is not known. The disease is most common in Caucasian males over 50 years of age. It has also been shown to be more common in those with diabetes, seizure disorders, HIV positive status, hypothyroidism, those who smoke and those who consume alcohol. Minor trauma and genetic predisposition may play a role. One or both hands may be affected. The ring finger is affected most often, followed by the little, middle, and index fingers. The MP and PIP joints are the most commonly affected joints.
Initially, a small, painless nodule develops in the connective tissue and eventually develops into a cord-like band. The cord tightens over time, pulling the affected finger towards the palm in an abnormal position. Extension of the finger becomes difficult to impossible with advanced cases. The goal of surgery (palmar fasciectomy) is to release or excise the fibrous attachments between the palmar fascia and the tissues around it, thereby releasing the contracture. Once released, finger movement should improve; although this is largely dependent upon the joint(s) being treated. Surgery is more effective if the contracture occurs in the metacarpophalangeal (MP) joint of only one finger and is less effective when two or more fingers and MP joints are involved. When the contracture occurs at the proximal interphalangeal (PIP) joint, the improvement rate decreases (Bird, 2007).
In 2012, van Rijssen and colleagues reported 5 year results of a clinical trial comparing percutaneous needle fasciotomy versus limited fasciectomy for the treatment of Dupuytren's contracture. One hundred eleven subjects with a minimal passive extension deficit of 30 degrees were randomized into one of two groups. The primary endpoint was recurrence. Ninety-three subjects reached the endpoint. The recurrence after 5 years was greater in the needle fasciotomy group than in the limited fasciectomy group (84.9 % vs. 20.9% respectively) and occurred sooner in the needle fasciotomy group (p=0.0001). Individual satisfaction was higher in the limited fasciectomy group, however, 53% of the subjects preferred percutaneous needle fasciotomy in case of recurrence.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
Dupuytren's Contracture Release
|Reviewed||08/14/2014||Medical Policy & Technology Assessment Committee (MPTAC). No change to criteria. References were updated.|
|Reviewed||08/08/2013||MPTAC. No change to criteria. References were updated.|
|Reviewed||08/09/2012||MPTAC review. Discussion/General Information and References updated.|
|Revised||08/18/2011||MPTAC review. Medically necessary contracture criteria for the metacarpophalangeal (MP) joint changed to 20 degrees. Discussion/General Information and References updated.|
|Revised||11/18/2010||MPTAC review. Criteria revised to include contracture measurements. Title changed. Discussion/General Information and References were updated.|
|Reviewed||11/19/2009||MPTAC review. Place of service removed. Discussion and references were updated.|
|Reviewed||11/20/2008||MPTAC review. No change to criteria. References were updated.|
|Reviewed||11/29/2007||MPTAC review. No change to criteria. References were updated.|
|Reviewed||12/07/2006||MPTAC review. References updated.|
|Revised||12/01/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
|Last Review |
|WellPoint Health Networks, Inc.||12/02/2004||Guideline||Dupuytren's Contracture Release|