Chelation Therapy
When the Edetate Calcium Disodium (J0600) is reported for chelation therapy for heavy metal poisoning (961.1, 961.2, 964.0, 984.0, 984.1, 984.8, 984.9, 985.1, 985.5, and 985.8) or Wilson's disease (275.1) (hepatolenticular degeneration), is reported, coverage for treatment is determined according to individual or group customer benefits.

Chelation therapy is also eligible for the treatment of the following conditions:

• Control of ventricular arrhythmias or heart block associated with digitalis toxicity
• Emergency treatment of hypercalcemia
• Thalassemia intermedia with hemochromatosis

The agent used for chelation therapy (J0600) should be denied as not covered when used to treat conditions other than those referenced above.

Chemical Endarterectomy
Use of Edetate Disodium (J3520) in the treatment of atherosclerosis, arteriosclerosis, or any other condition is considered experimental/investigational and, therefore, is not covered.  These are not FDA approved indications and scientific evidence does not demonstrate that safety and efficacy have been proven. A participating, preferred, or network provider can bill the member for the denied service.

M0300 represents either the intravenous administration of the chelating agent or the intravenous administration of EDTA (J3520).

When the chemical endarterectomy is not covered, all related services are also not covered (e.g., E/M, lab work, infusion services, administration [M0300], etc.).

When the administration code M0300 is billed with procedure code J3520 it will be denied as experimental/investigational. A participating, preferred, or network provider can bill the member for the denied service.

Description

Chelation Therapy
Chelation therapy is the treatment of choice for heavy metal poisoning.  The treatment consists of the intravenous administration (M0300) of chelating agents (e.g., Edetate Calcium Disodium (J0600), Endrate) to promote excretion of the offending metal.  Treatment may also include medical care.

Chemical Endarterectomy
Chemical endarterectomy is a form of treatment used for the removal of plaque or calcium.  It consists of the intravenous administration (M0300) of Edetate Disodium - EDTA (J3520) for conditions such as atherosclerosis, arteriosclerosis, or similar generalized conditions.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

The medical necessity guidelines are applied pre-payment for FEP.

PRN References

06/1997, Chelation therapy/chemical endarterectomy
10/1997, Chelation therapy/chemical endarterectomy policy will not change
02/1998, Coverage for chemical endarterectomy discontinued
06/2006, Blue Shield denies chemical endarterectomy administration

Chelation Therapy for Coronary Heart Disease: An Overview of All Clinical Investigations, American Heart Journal, Vol. 140, No. 1, 07/2000

Chelation Therapy for Ischemic Heart Disease, A Randomized Controlled Trial, Journal of the American Medical Association, Vol. 287, 01/2002

Edetate Calcium Disodium, USPDI - Vol. I, Edition 21, 2001 Micromedex, Inc.