Clinical UM Guideline


Subject:Surgical Treatment for Dupuytren's Contracture
Guideline #:   CG-SURG-11Current Effective Date:  10/08/2013
Status:ReviewedLast Review Date:   08/08/2013

Description

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:

Clinical Indications

Medically Necessary:

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.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  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.

CPT 
26040Fasciotomy, palmar (eg, Dupuytren's contracture); percutaneous
26045Fasciotomy, palmar (eg, Dupuytren's contracture); open, partial
  
ICD-9 Procedure 
82.35Other fasciectomy of hand
  
ICD-9 Diagnosis 
728.6Contracture of palmar fascia
  
ICD-10 ProcedureICD-10-PCS draft codes; effective 10/01/2014:
0MN70ZZRelease right hand bursa and ligament, open approach
0MN73ZZRelease right hand bursa and ligament, percutaneous approach
0MN74ZZRelease right hand bursa and ligament, percutaneous endoscopic approach
0MN80ZZRelease left hand bursa and ligament, open approach
0MN83ZZRelease left hand bursa and ligament, percutaneous approach
0MN84ZZRelease left hand bursa and ligament, percutaneous endoscopic approach
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
M72.0Contracture of palmar fascia
  
Discussion/General Information

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.

References

Peer Reviewed Publications:

  1. Dias JJ, Braybrooke J. Dupuytren's contracture: an audit of the outcomes of surgery. J Hand Surg [Br]. 2006; 31(5): 514-521.
  2. Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy: Complications and results. J Hand Surg Br. 2003; 28(5):427-431.
  3. Hovius SE, Kan HJ, Smit X, et al. Extensive percutaneous aponeurotomy and lipografting: A new treatment for Dupuytren disease. Plast Reconstr Surg. 2011;128(1):221-228.Lee LC, Zhang AY, Chong AK, et al. Expression of a novel gene, MafB, in Dupuytren's disease. J Hand Surg. 2006; 31(2): 211-218.
  4. van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren's disease: percutaneous needle fasciotomy versus limited fasciectomy. Plast Reconstr Surg. 2012; 129(2):469-477.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Bird B, Ball C, Balasuntharam P. Rehabilitation after surgery for Dupuytren's contracture. Cochrane Database Syst Rev. 2007; (2):CD006508.
  2. National Institute for Clinical Excellence (NICE). Needle fasciotomy for Dupuytren's contracture. Interventional Procedure Guidance 43. London, UK: NICE; February 2004.  Available at:  http://www.nice.org.uk/nicemedia/live/11116/31124/31124.pdf.   Accessed on July 11, 2013.
Web Sites for Additional Information
  1. American Academy Orthopedic Surgeons (AAOS). Dupuytren's Contracture. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=a00008.  Accessed on July 11, 2013.
  2. Dupuytrens Foundation. Available at: http://www.dupuytrenfoundation.org/. Accessed on July 11, 2013.
Index

Dupuytren's Contracture Release

History
StatusDateAction
Reviewed08/08/2013Medical Policy & Technology Assessment Committee (MPTAC).  No change to criteria.  References were updated.
Reviewed08/09/2012MPTAC review. Discussion/General Information and References updated.
Revised08/18/2011MPTAC review. Medically necessary contracture criteria for the metacarpophalangeal (MP) joint changed to 20 degrees. Discussion/General Information and References updated.
Revised11/18/2010MPTAC review. Criteria revised to include contracture measurements. Title changed. Discussion/General Information and References were updated.
Reviewed11/19/2009MPTAC review. Place of service removed. Discussion and references were updated.
Reviewed11/20/2008MPTAC review. No change to criteria. References were updated.
Reviewed11/29/2007MPTAC review. No change to criteria. References were updated.
Reviewed12/07/2006MPTAC review.  References updated.
Revised12/01/2005MPTAC review.  Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review DateDocument NumberTitle 

Anthem, Inc.

  None 
WellPoint Health Networks, Inc.12/02/2004GuidelineDupuytren's Contracture Release