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    v1.0.30
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsPriority Health Medicare Chelation Coverage | Open…
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    CurrentPriority Health MedicarePolicy 91077

    Chelation Therapy

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    This policy establishes medical necessity and coverage criteria for chelation therapy, including covered diagnoses and supporting diagnosis codes. It applies to Priority Health Medicare members, subject to specific benefits and applicable federal or state mandates.

    Policy Summary
    PayerPriority Health Medicare
    PolicyChelation Therapy
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective Date07/07/2026
    Next Review DateN/A
    Key ActionInclude an applicable ICD-10 diagnosis code documenting toxic effect from a metal or arsenic exposure with claims or medical-necessity submissions.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    6Medically necessary diagnostic categories
    4Examples of noncovered conditions
    3Chelating agents described
    ICD-10Diagnosis-code system
    Toxic metal exposure

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Clinical coding focus

    Medical Necessity and Noncovered Indications

    Medically Necessary Indications

    Chelation therapy is medically necessary when provided for any one of the following diagnoses or conditions:

    ONE of the following medically necessary indications

    • Biliary cirrhosis
    • Cooley's anemia
    • Cystinuria
    • Heavy metal poisoning, including poisoning from arsenic, copper, gold, iron, lead, or mercury
    • Wilson's disease
    • Iron overload secondary to multiple blood transfusions, such as in sickle cell anemia

    Noncovered Indications

    Chelation therapy as a treatment for all other conditions has not been proven to be effective and is considered not medically necessary.

    Any condition other than the listed medically necessary diagnoses or conditions is not medically necessary for chelation therapy.

    Chelation therapy is not medically necessary for conditions other than biliary cirrhosis, Cooley's anemia, cystinuria, heavy metal poisoning, Wilson's disease, or iron overload secondary to multiple blood transfusions. This exclusion includes autism spectrum disorders and other noncovered conditions.

    Examples of noncovered uses include autism spectrum disorders; cardiovascular disease, including atherosclerosis and coronary artery disease; neurodegenerative disorders, including Alzheimer's disease and other dementias; and stroke.

    ICD-10 Codes Supporting Medical Necessity

    Covered ICD-10 CodesICD-10Covered
    D56.0 - D56.9Thalassemia
    D57.00 - D57.819Sickle-cell disorders
    E72.00 - E72.09Disorders of amino-acid transport
    E83.00 - E83.09Disorders of copper metabolism
    E83.10 - E83.19Disorders of iron metabolism
    E83.52Hypercalcemia
    K74.3Primary biliary cirrhosis
    K74.4Secondary biliary cirrhosis
    K74.5Biliary cirrhosis, unspecified
    R18.8Ascites
    1–10 of 23
    1/3
    Covered ICD-10 CodesICD-10Covered
    T56.0x1A - T56.0x4SToxic effects of lead and its compounds, with listed encounter and intent extensions
    T56.1x1A - T56.1x4SToxic effect of mercury and its compounds, with listed encounter and intent extensions
    T56.2X1AToxic effect of chromium and its compounds, accidental (unintentional), initial encounter
    T56.2X1DToxic effect of chromium and its compounds, accidental (unintentional), subsequent encounter
    T56.2X2AToxic effect of chromium and its compounds, intentional self-harm, initial encounter
    T56.2X2DToxic effect of chromium and its compounds, intentional self-harm, subsequent encounter
    T56.2X3AToxic effect of chromium and its compounds, assault, initial encounter
    Covered ICD-10 CodesICD-10Covered
    T56.0x1A - T56.0x4SToxic effects of lead and its compounds
    T56.1x1A - T56.1x4SToxic effect of mercury and its compounds
    T56.2X1AToxic effect of chromium and its compounds, accidental (unintentional), initial encounter
    T56.2X1DToxic effect of chromium and its compounds, accidental (unintentional), subsequent encounter
    T56.2X2AToxic effect of chromium and its compounds, intentional self-harm, initial encounter
    T56.2X2DToxic effect of chromium and its compounds, intentional self-harm, subsequent encounter
    T56.2X3AToxic effect of chromium and its compounds, assault, initial encounter
    T56.2X3DToxic effect of chromium and its compounds, assault, subsequent encounter
    T56.2X4AToxic effect of chromium and its compounds; encounter designation shown in the excerpt without a complete description
    Covered ICD-10 CodesICD-10Covered
    T56.0x1A - T56.0x4SToxic effects of lead and its compounds
    Covered ICD-10 CodesICD-10Covered
    T56.1x1A - T56.1x4SToxic effect of mercury and its compounds
    Covered ICD-10 CodesICD-10Covered
    T56.2X1AToxic effect of chromium and its compounds, accidental (unintentional), initial encounter
    T56.2X1DToxic effect of chromium and its compounds, accidental (unintentional), subsequent encounter
    T56.2X2AToxic effect of chromium and its compounds, intentional self-harm, initial encounter
    T56.2X2DToxic effect of chromium and its compounds, intentional self-harm, subsequent encounter
    T56.2X3AToxic effect of chromium and its compounds, assault, initial encounter
    T56.2X3DToxic effect of chromium and its compounds, assault, subsequent encounter
    T56.2X4AToxic effect of chromium and its compounds, undetermined, initial encounter
    T56.2X4DToxic effect of chromium and its compounds, undetermined, subsequent encounter
    Covered ICD-10 CodesICD-10Covered
    T56.1x1A - T56.1x4SToxic effect of mercury and its compounds
    Covered ICD-10 CodesICD-10Covered
    T56.2X1AToxic effect of chromium and its compounds, accidental (unintentional), initial encounter
    T56.2X1DToxic effect of chromium and its compounds, accidental (unintentional), subsequent encounter
    T56.2X2AToxic effect of chromium and its compounds, intentional self-harm, initial encounter
    T56.2X2DToxic effect of chromium and its compounds, intentional self-harm, subsequent encounter
    T56.2X3AToxic effect of chromium and its compounds, assault, initial encounter
    T56.2X3DToxic effect of chromium and its compounds, assault, subsequent encounter
    T56.2X4AToxic effect of chromium and its compounds, undetermined, initial encounter
    T56.2X4DToxic effect of chromium and its compounds, undetermined, subsequent encounter
    Covered ICD-10 CodesICD-10Covered
    T56.3x1A - T56.3x4SToxic effect of cadmium and its compounds
    Covered ICD-10 CodesICD-10Covered
    T56.4x1A - T56.4x4SToxic effect of copper and its compounds
    Covered ICD-10 CodesICD-10Covered
    T56.2X1AToxic effect of chromium and its compounds, accidental (unintentional), initial encounter
    T56.2X1DToxic effect of chromium and its compounds, accidental (unintentional), subsequent encounter
    T56.2X2AToxic effect of chromium and its compounds, intentional self-harm, initial encounter
    T56.2X2DToxic effect of chromium and its compounds, intentional self-harm, subsequent encounter
    T56.2X3AToxic effect of chromium and its compounds, assault, initial encounter
    T56.2X3DToxic effect of chromium and its compounds, assault, subsequent encounter
    T56.2X4AToxic effect of chromium and its compounds, undetermined, initial encounter
    T56.2X4DToxic effect of chromium and its compounds, undetermined, subsequent encounter
    Covered ICD-10 CodesICD-10Covered
    T56.3x1A - T56.3x4SToxic effect of cadmium and its compounds
    Covered ICD-10 CodesICD-10Covered
    T56.4x1A - T56.4x4SToxic effect of copper and its compounds
    Covered ICD-10 CodesICD-10Covered
    T56.5x1A - T56.5x4SToxic effect of zinc and its compounds
    Covered ICD-10 CodesICD-10Covered
    T56.811A - T56.814SToxic effect of thallium
    Covered ICD-10 CodesICD-10Covered
    T56.2X1DToxic effect of chromium and its compounds, accidental (unintentional), subsequent encounter
    T56.2X2AToxic effect of chromium and its compounds, intentional self-harm, initial encounter
    T56.2X2DToxic effect of chromium and its compounds, intentional self-harm, subsequent encounter
    T56.2X3AToxic effect of chromium and its compounds, assault, initial encounter
    T56.2X3DToxic effect of chromium and its compounds, assault, subsequent encounter
    T56.2X4AToxic effect of chromium and its compounds, undetermined, initial encounter
    T56.2X4DToxic effect of chromium and its compounds, undetermined, subsequent encounter
    T56.3x1A - T56.3x4SToxic effect of cadmium and its compounds
    T56.4x1A - T56.4x4SToxic effect of copper and its compounds
    T56.5x1A - T56.5x4SToxic effect of zinc and its compounds
    1–10 of 13
    1/2
    Covered ICD-10 CodesICD-10Covered
    T56.2X2AToxic effect of chromium and its compounds, intentional self-harm, initial encounter
    T56.2X2DToxic effect of chromium and its compounds, intentional self-harm, subsequent encounter
    T56.2X3AToxic effect of chromium and its compounds, assault, initial encounter
    T56.2X3DToxic effect of chromium and its compounds, assault, subsequent encounter
    T56.2X4AToxic effect of chromium and its compounds, undetermined, initial encounter
    T56.2X4DToxic effect of chromium and its compounds, undetermined, subsequent encounter
    T56.3x1A - T56.3x4SToxic effect of cadmium and its compounds
    T56.4x1A - T56.4x4SToxic effect of copper and its compounds
    T56.5x1A - T56.5x4SToxic effect of zinc and its compounds
    T56.811A - T56.814SToxic effect of thallium
    1–10 of 13
    1/2
    Neutral ICD-10 CodesICD-10
    T56.2X2AToxic effect of chromium and its compounds, intentional self-harm, initial encounter
    T56.2X2DToxic effect of chromium and its compounds, intentional self-harm, subsequent encounter
    T56.2X3AToxic effect of chromium and its compounds, assault, initial encounter
    T56.2X3DToxic effect of chromium and its compounds, assault, subsequent encounter
    T56.2X4AToxic effect of chromium and its compounds, undetermined, initial encounter
    T56.2X4DToxic effect of chromium and its compounds, undetermined, subsequent encounter
    T56.3x1A - T56.3x4SToxic effect of cadmium and its compounds
    T56.4x1A - T56.4x4SToxic effect of copper and its compounds
    T56.5x1A - T56.5x4SToxic effect of zinc and its compounds
    T56.811A - T56.814SToxic effect of thallium
    1–10 of 14
    1/2
    Neutral ICD-10 CodesICD-10
    T56.2X2DToxic effect of chromium and its compounds, intentional self-harm, subsequent encounter
    T56.2X3AToxic effect of chromium and its compounds, assault, initial encounter
    T56.2X3DToxic effect of chromium and its compounds, assault, subsequent encounter
    T56.2X4AToxic effect of chromium and its compounds, undetermined, initial encounter
    T56.2X4DToxic effect of chromium and its compounds, undetermined, subsequent encounter
    T56.3x1A - T56.3x4SToxic effect of cadmium and its compounds
    T56.4x1A - T56.4x4SToxic effect of copper and its compounds
    T56.5x1A - T56.5x4SToxic effect of zinc and its compounds
    T56.811A - T56.814SToxic effect of thallium
    T56.891A - T56.894.SToxic effect of other metals
    1–10 of 13
    1/2
    Covered ICD-10 CodesICD-10Covered
    T56.2X2DToxic effect of chromium and its compounds, intentional self-harm, subsequent encounter
    T56.2X3AToxic effect of chromium and its compounds, assault, initial encounter
    T56.2X3DToxic effect of chromium and its compounds, assault, subsequent encounter
    T56.2X4AToxic effect of chromium and its compounds, undetermined, initial encounter
    T56.2X4DToxic effect of chromium and its compounds, undetermined, subsequent encounter
    T56.3x1A - T56.3x4SToxic effect of cadmium and its compounds
    T56.4x1A - T56.4x4SToxic effect of copper and its compounds
    T56.5x1A - T56.5x4SToxic effect of zinc and its compounds
    T56.811A - T56.814SToxic effect of thallium
    T56.891A - T56.894.SToxic effect of other metals
    1–10 of 13
    1/2
    Covered ICD-10 CodesICD-10Covered
    T56.2X3AToxic effect of chromium and its compounds, assault, initial encounter
    T56.2X3DToxic effect of chromium and its compounds, assault, subsequent encounter
    T56.2X4AToxic effect of chromium and its compounds, undetermined, initial encounter
    T56.2X4DToxic effect of chromium and its compounds, undetermined, subsequent encounter
    T56.3x1A - T56.3x4SToxic effect of cadmium and its compounds
    T56.4x1A - T56.4x4SToxic effect of copper and its compounds
    T56.5x1A - T56.5x4SToxic effect of zinc and its compounds
    T56.811A - T56.814SToxic effect of thallium
    T56.891A - T56.894.SToxic effect of other metals
    T56.91xA - T56.94xSToxic effect of unspecified metal
    1–10 of 13
    1/2
    Neutral ICD-10 Codes — Toxic effects of metalsICD-10
    T56.2X3AToxic effect of chromium and its compounds, assault, initial encounter
    T56.2X3DToxic effect of chromium and its compounds, assault, subsequent encounter
    T56.2X4AToxic effect of chromium and its compounds, undetermined, initial encounter
    T56.2X4DToxic effect of chromium and its compounds, undetermined, subsequent encounter
    T56.3x1A - T56.3x4SToxic effect of cadmium and its compounds
    T56.4x1A - T56.4x4SToxic effect of copper and its compounds
    T56.5x1A - T56.5x4SToxic effect of zinc and its compounds
    T56.811A - T56.814SToxic effect of thallium
    T56.891A - T56.894.SToxic effect of other metals
    T56.91xA - T56.94xSToxic effect of unspecified metal
    Neutral ICD-10 Codes — Toxic effects of arsenic and manganeseICD-10
    T57.0x1A - T57.0X4SToxic effect of arsenic and its compounds
    T57.2X1AToxic effect of manganese and its compounds, accidental (unintentional), initial encounter
    T57.2X1DToxic effect of manganese and its compounds, accidental (unintentional), subsequent encounter
    T57.2X2AToxic effect of manganese and its compounds
    Neutral ICD-10 CodesICD-10
    T56.2X3AToxic effect of chromium and its compounds, assault, initial encounter
    T56.2X3DToxic effect of chromium and its compounds, assault, subsequent encounter
    T56.2X4AToxic effect of chromium and its compounds, undetermined, initial encounter
    T56.2X4DToxic effect of chromium and its compounds, undetermined, subsequent encounter
    T56.3x1A - T56.3x4SToxic effect of cadmium and its compounds
    T56.4x1A - T56.4x4SToxic effect of copper and its compounds
    T56.5x1A - T56.5x4SToxic effect of zinc and its compounds
    T56.811A - T56.814SToxic effect of thallium
    T56.891A - T56.894.SToxic effect of other metals
    T56.91xA - T56.94xSToxic effect of unspecified metal
    1–10 of 14
    1/2
    Covered ICD-10 Codes — Toxic Effects of MetalsICD-10Covered
    T56.2X3DToxic effect of chromium and its compounds, assault, subsequent encounter
    T56.2X4AToxic effect of chromium and its compounds, undetermined, initial encounter
    T56.2X4DToxic effect of chromium and its compounds, undetermined, subsequent encounter
    T56.3x1A - T56.3x4SToxic effect of cadmium and its compounds
    T56.4x1A - T56.4x4SToxic effect of copper and its compounds
    T56.5x1A - T56.5x4SToxic effect of zinc and its compounds
    T56.811A - T56.814SToxic effect of thallium
    T56.891A - T56.894.SToxic effect of other metals
    T56.91xA - T56.94xSToxic effect of unspecified metal
    Covered ICD-10 Codes — Toxic Effects of Inorganic SubstancesICD-10Covered
    T57.0x1A - T57.0X4SToxic effect of arsenic and its compounds
    T57.2X1AToxic effect of manganese and its compounds, accidental (unintentional), initial encounter
    T57.2X1DToxic effect of manganese and its compounds, accidental (unintentional), subsequent encounter
    T57.2X2AToxic effect of manganese and its compounds, intentional self-harm, initial encounter

    Documentation and Submission Requirements

    Documentation Required

    Submit a supporting toxic-exposure diagnosis

    Include an applicable ICD-10 diagnosis code documenting toxic effect from a metal or arsenic exposure with claims or medical-necessity submissions.

    • Examples include toxic effects of chromium, cadmium, copper, zinc, thallium, other or unspecified metals, and arsenic.
    • Supporting code ranges include T56.2X2A-T56.2X4D, T56.3x1A-T56.3x4S, T56.4x1A-T56.4x4S, T56.5x1A-T56.5x4S, T56.811A-T56.814S, T56.891A-T56.894.S, T56.91xA-T56.94xS, and T57.0x1A-T57.0X4S.
    Denial Risk

    Avoid treatment for noncovered conditions

    Chelation therapy for conditions other than the listed medically necessary diagnoses is considered not medically necessary and may be denied. This includes autism spectrum disorders, cardiovascular disease such as atherosclerosis or coronary artery disease, neurodegenerative disorders such as Alzheimer’s disease or other dementias, stroke, and other nonlisted conditions.

    Clinical Background

    Chelation therapy involves administering a chelating substance that binds certain metals, renders them physiologically inactive, and allows them to be excreted in the urine. Agents described in the policy include ethylene diamine tetraacetic acid (EDTA), 2,3-dimercaptosuccinic acid (DMSA), and 2,3-dimercaptopropane-1-sulfonate (DMPS). The policy background describes their use in documented heavy-metal poisoning and related conditions, while noting that routine use for unsupported conditions is not established.

    Chelation Therapy and Agents

    Chelation therapy
    DefinitionChelation therapy is a process of administering a chelating substance that binds certain metals, renders them physiologically inactive, and allows them to be excreted in the urine.
    Chelating agents
    Ethylene diamine tetraacetic acidEDTA
    2,3-dimercaptosuccinic acidDMSA
    2,3-dimercaptopropane-1-sulfonateDMPS

    Administration Setting

    Note

    Office-based intravenous administration

    Chelation therapy is described as repeated intravenous administration in an office setting, commonly delivered over 1.5 to 3 hours in 500 mL to 1000 mL of normal saline. This is descriptive clinical background rather than a stated coverage requirement.

    • Typical protocols may involve repeated infusions delivered weekly or biweekly, followed by a less frequent maintenance schedule.
    Policy Summary
    PayerPriority Health Medicare
    PolicyChelation Therapy
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective Date07/07/2026
    Next Review DateN/A
    Key ActionInclude an applicable ICD-10 diagnosis code documenting toxic effect from a metal or arsenic exposure with claims or medical-necessity submissions.
    SourceLink
    On This Page
    Medical Necessity and Noncovered IndicationsICD-10 Codes Supporting Medical NecessityDocumentation and Submission RequirementsClinical BackgroundChelation Therapy and AgentsAdministration Setting
    • Covered indications include biliary cirrhosis, Cooley’s anemia, cystinuria, heavy metal poisoning, Wilson’s disease, and iron overload secondary to multiple blood transfusions.
    • The policy states that treatment for the listed noncovered conditions and other conditions outside the medically necessary indications has not been proven effective.