Medical Policy
Effective Date:09/18/1995 Title:Chelation Therapy
Revision Date:10/01/2015 Document:BI076:00
CPT Code(s):M0300, S9355
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Chelation Therapy is a title for a treatment which is used in two ways:

  1. Chelation therapy for heavy metal poisoning is covered. Chelating agents are used to bind heavy metals so that they can be excreted from the body in cases of acute (and rarely chronic) poisoning.
  2. Chelation therapy for all other purposes is not covered. No other use of chelation therapy has been shown to be safe and effective in any rigorous scientific way; it is considered experimental and is not a covered service.
Medical Statement

Chelation therapy is infusion of chelating agents for the treatment of the toxic effects of acute (or, rarely chronic) heavy metal poisoning.  There are several heavy metal antagonists utilized such as EDTA, deferoximine (Desferal), dimercaprol (BAL in oil), succimer (Chemet) and penicillamine (Cuprimine, Depen).  Chelation is covered and considered medically appropriate when used for the following:

  • Heavy metal poisoning (cadmium, copper, gold, iron, lead, mercury)
  • Arsenic poisoning
  • Biliary cirrhosis
  • Cooley’s anemia (thalassemia major)
  • Wilson’s disease
  • Sickle cell anemia
  • Secondary hemochromatosis (i.e., due to iron overload from multiple transfusions)

 

Codes Used In This BI:

M0300            Chelation Therapy

S9355                        Home infusion, chelation therapy

Limits

The safety and effectiveness of chelation therapy in the treatment of other conditions has not been established.
Reference

HCFA Coverage Issues Manual, Medical Procedures, #35-64 Chelation Therapy for the Treatment of Atherosclerosis, page 40.  http://www.hcfa.gov/pubforms/06_cim/ci35.htm

 

Hayes Manual, CHEL0601.41, February 27, 2000

 

Hayes Manual, CHEl0501.40, February 21, 2000
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.