Status Active

Medical and Behavioral Health Policy Section: Behavioral Health, Medicine Policy Number: II-03 Effective Date: 05/28/2014

Blue Cross and Blue Shield of Minnesota medical policies do not imply that members should not receive specific services based on the recommendation of their provider. These policies govern coverage and not clinical practice. Providers are responsible for medical advice and treatment of patients. Members with specific health care needs should consult an appropriate health care professional.

CHELATION THERAPY

Description: Chelation therapy is an established treatment for the removal of metal toxins by converting them to a chemically inert form that can be excreted in the urine. Chelation therapy consists of the intravenous or oral administration of chelating agents that remove metal ions such as lead, aluminum, mercury, arsenic, zinc, iron, copper, and calcium from the body. Specific chelating agents are used for particular heavy metal toxicities. For example, desferoxamine is used for patients with iron toxicity and calcium-EDTA is used for patients with lead poisoning.

While chelation therapy has been used effectively in patients with heavy metal toxicities, it has also been proposed as treatment for other indications, including atherosclerosis, rheumatoid arthritis, and autism.

Definitions: Ventricular arrhythmia: An irregular heart beat that originates in the ventricle, one of two lower chambers of the heart.

Heart block: A delay in the normal flow of electrical impulses that cause the heart to beat. These delays are classified according to their severity: first-, second-, or third-degree heart block.

Digitalis: Medication used to treat heart conditions, such as congestive heart failure and irregular heart beat. The most common form of digitalis is digoxin.

Dental amalgam: Alloy of mercury, and various other metals. used for dental fillings.

Policy: I. Chelation therapy may be considered MEDICALLY NECESSARY in the treatment of ANY of the following conditions: A. Control of ventricular arrhythmias or heart block, when associated with digitalis toxicity; OR B. Acute or long-term lead poisoning; OR

C. Extreme conditions of metal toxicity (e.g., aluminum, mercury, arsenic, zinc, iron, copper); OR D. Chronic iron overload (e.g., transfusional hemosiderosis or nontransfusion-dependent thalassemia); OR E. Copper storage disease (i.e., Wilson’s disease or hepatolenticular degeneration); OR F. Emergency treatment of hypercalcemia.

II. Chelation therapy is considered INVESTIGATIVE in the treatment of all other conditions including, but not limited to, the following: A. Coronary artery or peripheral vascular disease (e.g., atherosclerosis or secondary prevention of adverse cardiovascular events in patients with a history of myocardial infarction); B. Hypercholesterolemia; C. Multiple sclerosis; D. Arthritis; E. Diabetes; F. Scleroderma; G. Porphyria; H. Alzheimer’s disease; I. All mental health disorders; J. All substance-related disorders; K. Mercury release from dental amalgams.

Coverage: Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies.

Medicaid products and some self-insured plans may have additional policies and prior authorization requirements. Receipt of benefits is subject to all terms and conditions of the member’s summary plan description (SPD). As applicable, review the provisions relating to a specific coverage determination, including exclusions and limitations. Blue Cross reserves the right to revise, update and/or add to its medical policies at any time without notice.

For Medicare NCD and/or Medicare LCD, please consult CMS or National Government Services websites.

Refer to the Pre-Certification/Pre-Authorization section of the Medical Behavioral Health Policy Manual for the full list of services, procedures, prescription drugs, and medical devices that require Pre- certification/Pre-Authorization. Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.

Coding: The following codes are included below for informational purposes only, and are subject to change without notice. Inclusion or exclusion

of a code does not constitute or imply member coverage or provider reimbursement.

CPT: 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug

HCPCS: M0300 IV chelation therapy (chemical endarterectomy)

Policy Developed May 11, 2005 History: Most recent history: Reviewed August 10, 2011 Revised August 8, 2012 Revised August 14, 2013 Reviewed May 14, 2014

Cross Reference:

Current Procedural Terminology (CPT®) is copyright 2013 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

Copyright 2014 Blue Cross Blue Shield of Minnesota.