Chelation Therapy Last Review Date: February 10, 2017 Number: MG.MM.ME.48C3 Medical Guideline Disclaimer Definition Guideline Limitations/Exclusions
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1 Last Review Date: February 10, 2017 Number: MG.MM.ME.48C3 Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the patient meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request for prior authorization. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. EmblemHealth Services Company LLC, ( EmblemHealth ) has adopted the herein policy in providing management, administrative and other services to HIP Health Plan of New York, HIP Insurance Company of New York, Group Health Incorporated and GHI HMO Select, related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Definition Chelation therapy reduces the accumulations of essential heavy metals, such as iron and copper, or nonessential metals, such as lead and aluminum, in overload patients. Chelators bind with heavy metal ions and enhance the urinary and fecal excretion of toxic metals. Standard indications include iron overload, lead poisoning, copper toxicity and aluminum overload. Guideline Members are eligible for coverage of chelation therapy for heavy metal toxicity and overload conditions for any of the following: 1. Aluminum overload in members on chronic hemodialysis 2. Biliary cirrhosis 3. Transfusion-dependent inherited hemoglobinopathies (e.g., hemochromatosis, sickle cell anemia, thalassemia, etc.) 4. Cystinuria 5. Wilson's disease Documentation of heavy metal poisoning should include confirmation by whole-blood testing performed when the medical history or signs/symptoms are suggestive of heavy-metal exposure. Limitations/Exclusions The following are not considered medically necessary due to insufficient evidence of therapeutic value: 1. Any diagnoses/clinical conditions not listed in the covered indications above (e.g., mercury toxicity from dental amalgam fillings, as well as non-overload and chronic/progressive conditions [too numerous to list]). 2. Toxicity screening when symptoms are poorly defined (e.g., dysphoria, fatigue, malaise, vague pain, etc.) and when the medical history is not suggestive of heavy metal exposure. 3. Off-label use/unapproved chelators.
2 Page 2 of 7 Applicable Procedure Codes J0470 J0600 J0895 J3520 M0300 S9355 Injection, dimercaprol, per 100 mg Injection, edetate calcium disodium, up to 1,000 mg Injection, deferoxamine mesylate, 500 mg Edetate disodium, per 150 mg IV chelation therapy (chemical endarterectomy) Note: Code has 0 RVUs and is not reimbursable Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Applicable ICD-10 Diagnosis Codes D56.0 Alpha thalassemia D56.1 Beta thalassemia D56.2 Delta-beta thalassemia D56.3 Thalassemia minor D56.5 Hemoglobin E-beta thalassemia D56.8 Other thalassemias D56.9 Thalassemia, unspecified D57.00 Hb-SS disease with crisis, unspecified D57.01 Hb-SS disease with acute chest syndrome D57.02 Hb-SS disease with splenic sequestration D57.1 Sickle-cell disease without crisis D57.20 Sickle-cell/Hb-C disease without crisis D Sickle-cell/Hb-C disease with acute chest syndrome D Sickle-cell/Hb-C disease with splenic sequestration D Sickle-cell/Hb-C disease with crisis, unspecified D57.40 Sickle-cell thalassemia without crisis D Sickle-cell thalassemia with acute chest syndrome D Sickle-cell thalassemia with splenic sequestration D Sickle-cell thalassemia with crisis, unspecified D57.80 Other sickle-cell disorders without crisis D Other sickle-cell disorders with acute chest syndrome D Other sickle-cell disorders with splenic sequestration
3 Page 3 of 7 D Other sickle-cell disorders with crisis, unspecified D64.0 Hereditary sideroblastic anemia D64.1 Secondary sideroblastic anemia due to disease D64.2 Secondary sideroblastic anemia due to drugs and toxins D64.3 Other sideroblastic anemias E72.00 Disorders of amino-acid transport, unspecified E72.01 Cystinuria E72.02 Hartnup's disease E72.03 Lowe's syndrome E72.04 Cystinosis E72.09 Other disorders of amino-acid transport E83.00 Disorder of copper metabolism, unspecified E83.01 Wilson's disease E83.09 Other disorders of copper metabolism E83.10 Disorder of iron metabolism, unspecified E Hereditary hemochromatosis E Hemochromatosis due to repeated red blood cell transfusions E Other hemochromatosis E Hemochromatosis, unspecified E83.19 Other disorders of iron metabolism K74.4 Secondary biliary cirrhosis M1A.10x0 M1A.10x1 M1A.1110 M1A.1111 M1A.1120 M1A.1121 M1A.1190 M1A.1191 M1A.1210 M1A.1211 Lead-induced chronic gout, unspecified site, without tophus (tophi) Lead-induced chronic gout, unspecified site, with tophus (tophi) Lead-induced chronic gout, right shoulder, without tophus (tophi) Lead-induced chronic gout, right shoulder, with tophus (tophi) Lead-induced chronic gout, left shoulder, without tophus (tophi) Lead-induced chronic gout, left shoulder, with tophus (tophi) Lead-induced chronic gout, unspecified shoulder, without tophus (tophi) Lead-induced chronic gout, unspecified shoulder, with tophus (tophi) Lead-induced chronic gout, right elbow, without tophus (tophi) Lead-induced chronic gout, right elbow, with tophus (tophi)
4 Page 4 of 7 M1A.1220 M1A.1221 M1A.1290 M1A.1291 M1A.1310 M1A.1311 M1A.1320 M1A.1321 M1A.1390 M1A.1391 M1A.1410 M1A.1411 M1A.1420 M1A.1421 M1A.1490 M1A.1491 M1A.1510 M1A.1511 M1A.1520 M1A.1521 M1A.1590 M1A.1591 M1A.1610 M1A.1611 M1A.1620 M1A.1621 M1A.1690 M1A.1691 M1A.1710 M1A.1711 M1A.1720 Lead-induced chronic gout, left elbow, without tophus (tophi) Lead-induced chronic gout, left elbow, with tophus (tophi) Lead-induced chronic gout, unspecified elbow, without tophus (tophi) Lead-induced chronic gout, unspecified elbow, with tophus (tophi) Lead-induced chronic gout, right wrist, without tophus (tophi) Lead-induced chronic gout, right wrist, with tophus (tophi) Lead-induced chronic gout, left wrist, without tophus (tophi) Lead-induced chronic gout, left wrist, with tophus (tophi) Lead-induced chronic gout, unspecified wrist, without tophus (tophi) Lead-induced chronic gout, unspecified wrist, with tophus (tophi) Lead-induced chronic gout, right hand, without tophus (tophi) Lead-induced chronic gout, right hand, with tophus (tophi) Lead-induced chronic gout, left hand, without tophus (tophi) Lead-induced chronic gout, left hand, with tophus (tophi) Lead-induced chronic gout, unspecified hand, without tophus (tophi) Lead-induced chronic gout, unspecified hand, with tophus (tophi) Lead-induced chronic gout, right hip, without tophus (tophi) Lead-induced chronic gout, right hip, with tophus (tophi) Lead-induced chronic gout, left hip, without tophus (tophi) Lead-induced chronic gout, left hip, with tophus (tophi) Lead-induced chronic gout, unspecified hip, without tophus (tophi) Lead-induced chronic gout, unspecified hip, with tophus (tophi) Lead-induced chronic gout, right knee, without tophus (tophi) Lead-induced chronic gout, right knee, with tophus (tophi) Lead-induced chronic gout, left knee, without tophus (tophi) Lead-induced chronic gout, left knee, with tophus (tophi) Lead-induced chronic gout, unspecified knee, without tophus (tophi) Lead-induced chronic gout, unspecified knee, with tophus (tophi) Lead-induced chronic gout, right ankle and foot, without tophus (tophi) Lead-induced chronic gout, right ankle and foot, with tophus (tophi) Lead-induced chronic gout, left ankle and foot, without tophus (tophi)
5 Page 5 of 7 M1A.1721 M1A.1790 M1A.1791 M1A.18x0 M1A.18x1 M1A.19x0 M1A.19x1 T45.4X1A T45.4X2A T45.4X3A T45.4X4A T56.0X1A T56.0X2A T56.0X3A T56.0X4A T56.1X1A T56.1X2A T56.1X3A T56.1X4A T56.2X1A T56.2X2A T56.2X3A T56.2X4A T56.4X1A T56.4X2A T56.4X3A T56.4X4A T56.5X1A T56.5X2A T56.5X3A T56.5X4A Lead-induced chronic gout, left ankle and foot, with tophus (tophi) Lead-induced chronic gout, unspecified ankle and foot, without tophus (tophi) Lead-induced chronic gout, unspecified ankle and foot, with tophus (tophi) Lead-induced chronic gout, vertebrae, without tophus (tophi) Lead-induced chronic gout, vertebrae, with tophus (tophi) Lead-induced chronic gout, multiple sites, without tophus (tophi) Lead-induced chronic gout, multiple sites, with tophus (tophi) Poisoning by iron and its compounds, accidental (unintentional), initial encounter Poisoning by iron and its compounds, intentional self-harm, initial encounter Poisoning by iron and its compounds, assault, initial encounter Poisoning by iron and its compounds, undetermined, initial encounter Toxic effect of lead and its compounds, accidental (unintentional), initial encounter Toxic effect of lead and its compounds, intentional self-harm, initial encounter Toxic effect of lead and its compounds, assault, initial encounter Toxic effect of lead and its compounds, undetermined, initial encounter Toxic effect of mercury and its compounds, accidental (unintentional), initial encounter Toxic effect of mercury and its compounds, intentional self-harm, initial encounter Toxic effect of mercury and its compounds, assault, initial encounter Toxic effect of mercury and its compounds, undetermined, initial encounter Toxic effect of chromium and its compounds, accidental (unintentional), initial encounter Toxic effect of chromium and its compounds, intentional self-harm, initial encounter Toxic effect of chromium and its compounds, assault, initial encounter Toxic effect of chromium and its compounds, undetermined, initial encounter Toxic effect of copper and its compounds, accidental (unintentional), initial encounter Toxic effect of copper and its compounds, intentional self-harm, initial encounter Toxic effect of copper and its compounds, assault, initial encounter Toxic effect of copper and its compounds, undetermined, initial encounter Toxic effect of zinc and its compounds, accidental (unintentional), initial encounter Toxic effect of zinc and its compounds, intentional self-harm, initial encounter Toxic effect of zinc and its compounds, assault, initial encounter Toxic effect of zinc and its compounds, undetermined, initial encounter
6 Page 6 of 7 T56.6X1A T56.6X2A T56.6X3A T56.6X4A T56.811A T56.812A T56.813A T56.814A T56.891A T56.892A T56.893A T56.894A T56.91xA T56.92xA T56.93xA T56.94xA T57.0X1A T57.0X2A T57.0X3A T57.0X4A Toxic effect of tin and its compounds, accidental (unintentional), initial encounter Toxic effect of tin and its compounds, intentional self-harm, initial encounter Toxic effect of tin and its compounds, assault, initial encounter Toxic effect of tin and its compounds, undetermined, initial encounter Toxic effect of thallium, accidental (unintentional), initial encounter Toxic effect of thallium, intentional self-harm, initial encounter Toxic effect of thallium, assault, initial encounter Toxic effect of thallium, undetermined, initial encounter Toxic effect of other metals, accidental (unintentional), initial encounter Toxic effect of other metals, intentional self-harm, initial encounter Toxic effect of other metals, assault, initial encounter Toxic effect of other metals, undetermined, initial encounter Toxic effect of unspecified metal, accidental (unintentional), initial encounter Toxic effect of unspecified metal, intentional self-harm, initial encounter Toxic effect of unspecified metal, assault, initial encounter Toxic effect of unspecified metal, undetermined, initial encounter Toxic effect of arsenic and its compounds, accidental (unintentional), initial encounter Toxic effect of arsenic and its compounds, intentional self-harm, initial encounter Toxic effect of arsenic and its compounds, assault, initial encounter Toxic effect of arsenic and its compounds, undetermined, initial encounter Z Contact with and (suspected) exposure to lead References American Academy of Family Physicians. Chelation therapy Accessed February 22, CMS. National Coverage Determination (NCD) for Chelation Therapy for Treatment of Atherosclerosis. Accessed February 22, CMS. National Coverage Determination (NCD) for Ethylenediamine-Tetra-Acetic (EDTA) Chelation Therapy for Treatment of Atherosclerosis. Accessed February 22, Hayes Inc. Medical Technology Directory. Chelation Therapy, Non-Overload Conditions. Lansdale, PA: Hayes, Inc.; October Last updated November Specialty matched clinical peer review.
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Clinical Policy: Cochlear Implant Replacements Reference Number: CP.MP.14
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Clinical Policy: Homocysteine Testing Reference Number: CP.MP.121
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Product Name or Headline
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Clinical Policy: Cochlear Implant Replacements
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Clinical Policy: Aflibercept (Eylea) Reference Number: CP.PHAR.184
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Excessive skin on the eyelids due to chronic blepharedema, which physically stretches the skin.
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Sympathetic Electrical Stimulation Therapy for Chronic Pain
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Clinical Policy: Electric Tumor Treating Fields (Optune) Reference Number: CP.MP.145
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Clinical Policy: (Cerezyme) Reference Number: CP.PHAR.154 Effective Date: 02.01.16 Last Review Date: 05.18 Line of Business: Commercial, HIM, Medicaid Coding Implications Revision Log See Important Reminder
Clinical Policy: Trigger Point Injections for Pain Management
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Clinical Policy: Posterior Tibial Nerve Stimulation for Voiding Dysfunction Reference Number: CP.MP.133
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APPLICABLE CODES S9355 DESCRIPTION OF SERVICES
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Clinical Policy: Methoxy polyethylene glycol-epoetin beta (Mircera) Reference Number: CP.CPA.322 Effective Date: 06.01.18 Last Review Date: 05.18 Line of Business: Commercial Coding Implications Revision
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