S9355, Home infusion therapy, chelation therapy; administrative services, professional
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- None specified in this policy. (The CPB does not list required medical records, test results, or other documentation for coverage because the services are considered experimental/investigational and not covered.)
- Documentation that the individual meets DSM-5 TR criteria for Autism Spectrum Disorder when behavioral health treatment is requested
- Behavioral health evaluation / psychiatric diagnostic evaluation report (CPT 90791 / 90792) when applicable
- Results and documentation of autism-specific developmental screening instruments (CPT 96110) and developmental test administration/interpretation reports (CPT 96112, 96113) when those services are billed
Key Coverage Criteria
- Chelation therapy is covered as medically necessary for heavy metal toxicity and overload conditions (e.g., iron, copper, lead, aluminum).
- Aetna considers the use of devices to image the jawbones to diagnose NICO or NICO-type conditions experimental and investigational.
- None. The policy states that surgery, other therapies, bone graft replacement, and devices to image the jawbones (including ultrasonograph bone densitometer) for diagnosis or treatment of neuralgia inducing cavitational osteonecrosis (NICO) or NICO-type conditions are considered experimental and investigational and therefore are not covered.
- Behavioral health evaluation including psychiatric examination for suspected or known ASD
- Electroencephalogram (EEG) when there is suspicion of a seizure
- Evaluation by speech and language pathologist
11 Active Policies
ANTHEM-CG-MED-90, CG-MED-90 Chelation Therapy
UHC-POL-chelation-therapy-non-overload-conditions, Chelation Therapy
AETNA-CPB-0642, Neuralgia Inducing Cavitational Osteonecrosis (NICO) and Ultrasonograph Bone Densitometer to Detect NICO
THE801.008, Chelation Therapy for Off-Label Uses
BCBSIL-THE801.008, Chelation Therapy for Off-Label Uses
Related Codes
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