CurrentCignaPolicy IP0138

Dimercaprol and Edetate Calcium Disodium Coverage Policy

Defines medical necessity, authorization duration, non-covered uses, and coding/billing for dimercaprol (BAL in Oil) and edetate calcium disodium (Calcium Disodium Versenate) under Cigna benefit plans.

Policy Summary

PayerCigna

PolicyDimercaprol and Edetate Calcium Disodium Coverage Policy

Policy CodePolicy IP0138

Change TypeNo material change

Effective DateOct 1, 2023

Next Review DateOct 1, 2024

Key ActionProviders must meet the policy's clinical criteria to obtain prior authorization; initial approval duration is up to 10 days.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or criteria.

2Medically covered agents

10Initial authorization (days)

>=44 μg/dLLead level threshold

2 hoursDimercaprol window after mercury ingestion

Coverage Summary

Defines medical necessity, authorization duration, non-covered uses, and coding/billing for dimercaprol and edetate calcium disodium under Cigna benefit plans. Policy Number: IP0138. Subject: Dimercaprol and Edetate Calcium Disodium coverage. Status: CURRENT. Effective Date: 10/1/2023. Next Review Date: 10/1/2024.

Not Covered and Exclusions

Chelation should not be used as a substitute for eliminating or reducing exposure; effective measures to remove the source of exposure must be employed. Treatment of metal toxicity that arises out of or in the course of employment is generally excluded under most Cigna benefit plans and may be denied. Additionally, many other uses of chelation (for example, atherosclerotic vascular disease, autism spectrum disorders, treatment of 'mercury toxicity' from dental amalgam fillings, and other unspecified heavy metal poisonings) are considered experimental, investigational, or unproven and not covered.

Coding

Covered HCPCS / J-codesHCPCSCovered

J0470	Injection, dimercaprol, per 100 mg
J0600	Injection, edetate calcium disodium, up to 1,000 mg

Billing Rule

Coding adherence

Report J0470 for dimercaprol per 100 mg and J0600 for edetate calcium disodium up to 1,000 mg when medically necessary. Note that deleted codes and codes which are not effective at the time the service is rendered may not be eligible for reimbursement.

Provider Actions

Prior Authorization

Prior authorization required per policy

This coverage policy supports medical necessity review and requires prior authorization. Providers must meet the policy's clinical criteria to obtain authorization. Initial approval duration is up to 10 days.

J0470
J0600

Documentation Required

Laboratory confirmation requirement

For arsenic, gold, or mercury overload or toxicity, confirmatory appropriate laboratory results (for example, blood, plasma, and/or urine) or clinical findings consistent with toxicity must be documented.

Denial Risk

Occupational exposure exclusion

Treatment for metal toxicity that occurs as a result of occupational exposure is generally excluded under most Cigna benefit plans and may be denied.

Background and Evidence

Dimercaprol and edetate calcium disodium are chelating agents indicated for specific heavy metal poisonings. FDA labeling and product information note clinical indications and limitations (for example, dimercaprol for arsenic, gold, and mercury poisoning and edetate calcium disodium for reduction of lead levels), and safety concerns have been raised when agents are misused (for example, deaths from mistaken administration of Edetate Disodium instead of Edetate Calcium Disodium). Chelation therapy should not replace effective measures to eliminate or reduce further exposure to the offending metal.

RAFT / TACT trial: Disodium EDTA chelation modestly reduced some cardiovascular outcomes in post-MI patients but evidence insufficient to support routine use for atherosclerotic disease (Lamas, 2013).