Anthem Blue Cross Connecticut CG-MED-90 Chelation Therapy Form

This document addresses the uses of chelation therapy. Chelation therapy uses naturally occurring or chemically designed molecules to reduce potentially dangerous levels of heavy metals within the body. Chelation therapy is routinely performed for cases of iron overload, lead poisoning, copper toxicity, and other heavy metal conditions. This document is not applicable to agents used for the treatment of drug overdose or toxicities.

Clinical Indications

Medically Necessary:

Chelation therapy is considered medically necessary treatment for individuals with relevant clinical findings suggestive of heavy metal toxicity and a probable exposure history in any of the following conditions when confirmed by laboratory testing*:

1. Individuals with disorders of iron metabolism (for example, primary or secondary hemochromatosis); or
2. Lead overload in cases of acute or long-term lead exposure; or
3. Individuals with disorders of copper metabolism (for example, Wilson’s disease); or
4. Arsenic, mercury, iron, copper, or gold poisoning when long-term exposure and toxicity has been confirmed; or
5. Aluminum overload in individuals on chronic hemodialysis.

*Note: Laboratory testing to confirm heavy metal toxicity should include blood or plasma specimens. In the case of suspected arsenic or mercury toxicity, it may be more appropriate to confirm diagnosis through a non-challenged urinalysis.

Not Medically Necessary:

Chelation therapy is considered not medically necessary for the treatment of all other conditions, including but not limited to, when the medically necessary criteria above have not been met.