S9355 — Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
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
- 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").
- 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
11 Active Policies
CIGNA-0447 — Autism Spectrum Disorders/Pervasive Developmental Disorders: Assessment and Treatment - (0447)
UHC-POL-chelation-therapy-non-overload-conditions — Chelation Therapy
AETNA-CPB-0642 — Neuralgia Inducing Cavitational Osteonecrosis (NICO) and Ultrasonograph Bone Densitometer to Detect NICO
ANTHEM-CG-MED-90 — CG-MED-90 Chelation Therapy
Related Codes
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