B46.0 — Pulmonary mucormycosis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For cadmium toxicity: blood cadmium level documentation (values > 5 µg/dL suggest acute toxicity) and clinical context.
- For acute iron intoxication: clinical notes supporting diagnosis of acute iron poisoning and adjunctive use of deferoxamine per FDA indication.
- For aluminum toxicity in dialysis patients: serum aluminum levels (baseline and post‑DFO delta sAl), documentation of dialysis schedule, and evidence to support alternative DFO administration timing (e.g., severe intoxication with post‑DFO serum Al > 300 µg/L suggests giving DFO 5 hours prior to dialysis).
- For lead poisoning: blood lead level (BLL) values with dates to support thresholds (children: ≥ 45 µg/dL for moderate/severe chelation; 20–44 µg/dL for selected oral chelation; adults: thresholds as documented: > 80 µg/dL; 60–80 µg/dL if symptomatic; 40–60 µg/dL may be considered if continued symptoms after removal from exposure).
Key Coverage Criteria
- Myelodysplastic syndromes (MDS): Consideration of iron chelation (once‑daily subcutaneous deferoxamine or oral deferasirox) to decrease iron overload in IPSS Low or Intermediate‑1 patients who have received or are anticipated to receive > 20 RBC transfusions, patients for whom ongoing RBC transfusions are anticipated, and patients with serum ferritin > 2,500 ng/mL (aiming for target ferritin < 1,000 ng/mL as per NCCN guidance).
- Thalassemia major and transfusion‑dependent anemias: Iron chelation therapy to prevent/treat transfusional iron overload (deferoxamine, deferasirox, etc.).
- Renal failure with aluminum toxicity: Deferoxamine indicated for aluminum overload in dialysis patients (DFO shown to improve symptoms and bone histology).
- Selected infectious or adjunctive uses described in literature: iron chelation as adjunct in management of zygomycosis (limited experience) and experimental/ investigational uses summarized (e.g., topical EDTA for cataract in animal/early studies).
- Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test: NO specific code (noted in the CPB).
- Deferoxamine (Desferal) injection is medically necessary for: Transfusional iron overload in members with chronic anemia when the pretreatment serum ferritin level is consistently greater than 1000 mcg/L.
3 Active Policies
AMBETTER-CP.MP.242 — Pulmonary Function Testing
AETNA-CPB-0234 — Chelation Therapy
ANTHEM-CG-MED-73 — CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
Related Codes
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