00127
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Chelation therapy is consideredmedically necessarytreatment for individuals with relevant clinical findings suggestive of heavy metal toxicity and a probable exposure history inanyof the following conditions when confirmed by laboratory testing*:
- Individuals with disorders of iron metabolism (for example, primary or secondary hemochromatosis);or
- Lead overload in cases of acute or long-term lead exposure;or
- Individuals with disorders of copper metabolism (for example, Wilsonâs disease);or
- Arsenic, mercury, iron, copper, or gold poisoning when long-term exposure and toxicity has been confirmed;or
- Aluminum overload in individuals on chronic hemodialysis.
1 Active Policy
ANTHEM-CG-MED-90 — CG-MED-90 Chelation Therapy
Related Codes
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