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Medical Policy: 08.01.06
Original Effective Date: April 2001
Reviewed: January 2012
Revised: January 2007
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Chelation therapy is a process of oral or intravenous infusion of the chelating agents (e.g. EDTA, dimercaprol, deferoxamine) that remove metal ions such as calcium, iron, copper, zinc or lead. Chelating agents firmly bind with metallic ions to form a new compound that can be eliminated from the body.
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Prior Approval:
Not applicable
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Policy:
Chelation therapy may be considered medically necessary for the following diagnoses:
- Extreme conditions of metal toxicity, including thalassemia with hemosiderosis
- Digitalis toxicity with ventricular arrhythmia or heart block
- Emergency treatment of Hypercalcemia
- Wilson’s disease (hepatolenticular degeneration)
- Primary hemochromatosis in those patients unable to tolerate intermittent phlebotomy
- Secondary hemochromatosis resulting from transfusion dependent anemias
Chelation therapy is considered investigational for any condition not listed above including, but not limited to:
- Alzheimer's
- Autism
- Chemical endarterectomy for atherosclerosis
- Coronary artery disease
- Peripheral vascular disease
- Multiple Sclerosis
- Arthritis
- Hypoglycemia
- Diabetes
- Cancer
- Psychiatric disorders
- Substance abuse disorders
- Chronic fatigue syndrome secondary to dental amalgam therapy
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Procedure Codes and Billing Guidelines:
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- M0300 IV chelation therapy for chemical endarterectomy (Non-Covered)
- Calcium EDTA; J0600
- Dimercaprol; J0470
- Deferoxamine; J0895
- Edetate disodium; J3520
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Selected References:
- The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
- Isselbacher, et.al. Harrison’s Principles of Internal Medicine, McGraw Hill, 13th edition 1145-2496.
- R.E. Rakel (ed) Conn’s Current Therapy, 1998., W B Saunders Co.1998;342, 361-362, 1238, 1243-1245.
- Knudtson ML, Wyse DG, et al. Chelation Therapy for Ischemic Heart Disease: A Randomized Controlled Trial JAMA January 2002; 287(4), 481-486.
- American Heart Association. Chelation Therapy: AHA Recommendation. Accessed 2/16/2005; www.americanheart.org
- Bonow: Braunwald’s Heart Disease. A Textbook of Cardiovascular Medicine, 9th ed. Philadelphia, PA; Saunders; 2011 Ch. 57-Stable Ischemic Heart Disease.
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Policy History:
Date Reason Action
January 2011 Annual review Policy renewed
January 2012 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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