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Medical Policy: 08.01.06
Original Effective Date: April 2001
Reviewed: March 2008
Revised: January 2007
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
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.
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, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- HCPCS code 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
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave.
Des Moines, IA 50309
*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
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.
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