CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicaid_Chemet.20250604

Policy governs authorization criteria and coverage duration for Chemet (succimer) capsules for treatment of acute lead poisoning in members aged 12 months and older, including specialist prescribing and monitoring requirements.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicaid_Chemet.20250604

Policy CodePolicy N/A

Change TypeDocument review

Effective DateFeb 1, 2022

Next Review Date

Key ActionAuthorization may be granted only when all listed criteria are met including age >=12 months, blood lead level 45-69 mcg/L, specialist prescribing/consultation, indication for acute treatment, and monitoring for members with liver disease.

SourceLink

POLICY UPDATE CHANGES

Document review dates updated through 6/2025; core clinical criteria unchanged.

1 monthCovered Duration

45-69 mcg/LCovered Blood Lead Level Range

>=12 monthsMinimum Age

Coverage Summary

Coverage stance: covered_with_criteria for Chemet (succimer) capsules for acute lead poisoning (policy subject).

Scope summary: Policy governs authorization criteria and coverage duration for Chemet (succimer) capsules for treatment of acute lead poisoning in members aged 12 months and older, including specialist prescribing and monitoring requirements.

Criteria for Approval (Initial Therapy)

Criteria for Approval

An authorization may be granted when all the following criteria are met:

ALL of the following

Age: Member is 12 months of age or older>=12 months
exact numeric range in policy
Blood lead level: Member has documented diagnosis of lead poisoning as evidenced by blood lead levels between 45-69 mcg/L45-69 mcg/L
Indication: Medication is being used for acute lead poisoning and not for prophylaxis against lead poisoning in a lead-containing environment
Prescriber: Medication is prescribed by or in consultation with a provider who specializes in chelation therapy (e.g., a medical toxicologist or poison control specialist)
Specialist in chelation therapy
Monitoring: Members with liver disease are routinely monitored (CBC with differential, LFTs, platelet count and serum creatinine/BUN)
monitoring requirement for members with liver disease

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title": "Criteria for Approval"

Provider Actions & Authorization Requirements

Prior Authorization

Authorization required when criteria met

Authorization may be granted only when all listed criteria are met: member age at least 12 months; documented blood lead level 45-69 mcg/L; medication is for acute lead poisoning (not prophylaxis); prescribed by or in consultation with a chelation therapy specialist; members with liver disease are routinely monitored.

Age ≥ 12 months
Blood lead level 45-69 mcg/L
Prescribed by or in consultation with a chelation therapy specialist (e.g., medical toxicologist or poison control specialist)
For acute treatment only (not prophylaxis)
Monitoring for members with liver disease (CBC with differential, LFTs, platelets, serum creatinine/BUN)

Documentation Required

Clinical documentation of lead level and specialist involvement

Provider must document blood lead level within 45-69 mcg/L and that medication is prescribed by or in consultation with a chelation therapy specialist; document monitoring plan for members with liver disease.

Document blood lead level within 45-69 mcg/L
Document specialist prescribing or consultation
Document monitoring plan for members with liver disease

Billing Rule

Coverage duration

Coverage is limited to 1 month per authorization.

Limit: 1 month per authorization

Applicable Codes

No specific code groups were provided in the brief. Please populate any applicable NDC, HCPCS, or CPT codes from the payer's coding list if available; if none apply, leave the code_table empty.

If applicable, use the prescribing information as the source for NDC(s) and other product identifiers.

Clinical Evidence & References

References:

Chemet [prescribing information]. Ovation Pharmaceuticals: January 2023.

No other clinical trials or quantitative evidence were provided in the brief.

Background

Chemet (succimer) is indicated as a chelating agent for treatment of acute lead poisoning (policy subject: Chemet (succimer) capsules coverage for acute lead poisoning).

Policy references the Chemet prescribing information (Ovation Pharmaceuticals, January 2023).

Scope context: Policy governs authorization criteria and coverage duration for Chemet (succimer) capsules for treatment of acute lead poisoning in members aged 12 months and older, including specialist prescribing and monitoring requirements.

Specialist in chelation therapy: Provider who specializes in chelation therapy (e.g., a medical toxicologist or poison control specialist).

Revision History

02/01/2022effective_date

Policy effective date: 02/01/2022.

11/2021reviewed

Document review.

07/2023reviewed

Document review.

06/2024reviewed

Document review.

06/2025reviewedLatest

Document review dates updated through 6/2025; core clinical criteria unchanged.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicaid_Chemet.20250604

Policy CodePolicy N/A

Change TypeDocument review

Effective DateFeb 1, 2022

Next Review Date

SourceLink

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