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
- Documented diagnosis of metal poisoning or metal overload established by validated testing in appropriate biological samples (policy and professional society statements: "documented metal intoxication, which has been diagnosed using validated tests in appropriate biological samples").
- Diagnostic workup must consider the individual's history, an appropriate choice of testing methods, and the use of accurate and specific reference values (from Description of Services).
- For iron overload cases (examples in Clinical Evidence), relevant objective testing/results should be available, e.g., serum ferritin, liver iron concentration (LIC) measurements (MRI/R2*/R2 techniques), and cardiac MRI T2* where applicable.
- For lead poisoning, documented blood lead level(s) consistent with clinical diagnosis (policy cites lead poisoning as an established indication).
Key Coverage Criteria
- Chelation for heavy metal toxicity and overload conditions (e.g., iron, copper, lead, aluminum) is proven and medically necessary.
- Treatment of iron overload (examples in evidence: transfusion-dependent thalassemia, transfusion-associated iron overload in sickle cell disease and other anemias, low- to intermediate-risk myelodysplastic syndrome with iron overload) — described throughout Clinical Evidence as appropriate contexts for iron chelation therapy.
- Use of FDA-approved chelating agents when used for metal poisoning or iron overload treatment (policy: "Chelation therapy, using FDA-approved chelating agents, is approved when used for metal poisoning or iron overload treatment. Use is limited to FDA-approved indications for each chelation agent, as referenced in a generally recognized drug compendium").
- 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
9 Active Policies
UHC-POL-chelation-therapy-non-overload-conditions — Chelation Therapy
ANTHEM-CG-MED-90 — CG-MED-90 Chelation Therapy
UMR-POL-UMR-chelation-therapy-non-overload-conditions — Chelation Therapy
SUREST-POL-SUREST-chelation-therapy-non-overload-conditions — Chelation Therapy
BCBSIL-THE801.008
Related Codes
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