J3520, Edetate disodium, per 150 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Clinical documentation demonstrating the therapy is effective for the relevant diagnosis or procedure.
- For drug therapy, documentation of proposed dose, frequency, and duration and a citation to at least one authoritative source or FDA labeling supporting those parameters.
- References or citations to supporting authoritative sources (e.g., MCG, DrugDex, NCCN, peer‑reviewed literature) used to justify medical necessity.
- Documentation of a clinical or genetic diagnosis of a disease/syndrome/disorder that includes low tone neuromuscular impairment, neurological impairment, or cognitive impairment.
Key Coverage Criteria
- Chelation therapy is covered as medically necessary for heavy metal toxicity and overload conditions (e.g., iron, copper, lead, aluminum).
- 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
9 Active Policies
ANTHEM-CG-MED-90, CG-MED-90 Chelation Therapy
UHC-POL-chelation-therapy-non-overload-conditions, Chelation Therapy
THE801.008, Chelation Therapy for Off-Label Uses
BCBSIL-THE801.008, Chelation Therapy for Off-Label Uses
BCBSMT-THE801.008, Chelation Therapy for Off-Label Uses
Related Codes
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