Currentpriority healthPolicy BILLING POLICY No. 159

Chelation Therapy

Defines Priority Health's billing, documentation, coding, and reimbursement guidance for chelation therapy services for Commercial, Medicare (follow CMS), and Medicaid (follow MDHHS) members. Affects providers submitting claims for chelation infusions, injections, home infusion per diem, and related drug codes.

Policy Summary

Payerpriority health

PolicyChelation Therapy

Policy CodePolicy BILLING POLICY No. 159

Change TypeNew policy

Effective DateOct 16, 2025

Next Review Date

Key ActionObtain prior authorization for S9355 per diem and complete required documentation (diagnosis, lab confirmation, dosing, and follow-up); for Medicare members when indications are not covered by NCD/LCD/policy, submit a PreService Organization Determination (PSOD).

SourceLink

POLICY UPDATE CHANGES

New policy created for Chelation Therapy (Policy No. 159) with effective date Oct 16, 2025.

10+CPT/HCPCS/J-codes and service codes listed

S9355Home infusion per diem requires prior authorization

CPT 96365/96366IV infusion codes subject to CCI edits with injection codes

Medicare Pre-Service & Documentation Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Medicare pre-service determination requirement

When indications do not meet NCD, local LCD or specific medical policy for Medicare members:

ALL of the following

A PreService Organization Determination (PSOD) must be completed for Medicare members when clinical indication is not covered by an NCD, LCD, or specific medical policy.

Documentation requirements to support chelation therapy

Provider must include complete documentation in the medical record to substantiate the procedure:

ALL of the following

Patient's diagnosis and clinical indication
Laboratory confirmation of heavy metal toxicity or iron overload
Dosing schedule and medication administered
Patient response and follow-up plan

Relevant CPT, HCPCS and Per-Diem Codes

Infusion procedure codesCPT

96365	IV infusion, initial, up to 1 hour
96366	IV infusion, each additional hour

Drug/injection HCPCS J-codes and related codesHCPCS

J0600	Injection, edetate calcium disodium, up to 1,000 mg
J0470	Injection, dimercaprol, per 100 mg
J0895	Injection, deferoxamine mesylate, 500 mg
J3520	Edetate disodium, per 150 mg
J8499	Prescription drug, oral, non-specified (if applicable)
J0899	Prescription drug, non-chemotherapy, non-specified

Home infusion per diemHCPCSCovered

S9355

Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem - requires prior auth

Prior Auth, Documentation & Billing Rules

Prior Authorization

Prior authorization for S9355 (home infusion) and Medicare PSOD

S9355 (home infusion per diem) requires prior authorization. For Medicare members, when the clinical indication does not meet an NCD, local LCD, or specific medical policy, a PreService Organization Determination (PSOD) must be completed before services are provided.

S9355

Documentation Required

Required clinical documentation

Providers must maintain complete documentation in the medical record to substantiate chelation therapy services, including the specific clinical indications and related evidence.

Patient's diagnosis and clinical indication
Laboratory confirmation of heavy metal toxicity or iron overload
Dosing schedule and medication administered
Patient response and follow-up plan

Billing Rule

CCI/Modifier guidance for infusion and injection codes

CPT 96365 and 96366 are subject to CCI/NCCI edits and cannot be billed together with injection J‑codes unless properly documented; use of modifier -59 or the appropriate X{EPSU} modifiers may be required to indicate the injection was a separate and distinct service. Incorrect modifier application may result in claim denials.

Affected codes: 96365, 96366, J0600, J0470, J0895, J3520
Note: Denial risk if modifiers are misapplied

Billing Rule

Fee schedule and reimbursement

Reimbursement rates for the listed codes are available in Priority Health’s standard fee schedules (login required). Claims must use industry-standard CPT/HCPCS/revenue codes and be fully documented per policy and contract to support payment.

Denial Risk

Potential actions for noncompliance

If policy, coding, billing, or contractual requirements are not followed, Priority Health may reject or deny claims, recover or recoup payments, or perform pre- or post-claim reviews for payment integrity.

Possible actions: claim rejection/denial, payment recovery/recoupment, pre- or post-claim review

Scope & Purpose

This policy defines Priority Health's billing, documentation, coding, and reimbursement guidance for chelation therapy services for Commercial members and notes that Medicare follows CMS guidance and Medicaid follows MDHHS guidance. It applies to providers submitting claims for chelation infusions, chelation injections, the S9355 home infusion per diem, and related drug codes identified for chelation therapy. (Applies to: Commercial; Medicare follows CMS; Medicaid follows MDHHS.)

Affected services and codes called out in the policy include IV infusion procedure codes 96365 (initial up to 1 hour) and 96366 (each additional hour), drug and injection HCPCS/J-codes such as J0600, J0470, J0895, J3520 and related prescription drug codes, and the home infusion per diem S9355 which requires prior authorization.

Providers are responsible for complete and thorough documentation to substantiate the service. Required medical record elements include the patient's diagnosis and clinical indication, laboratory confirmation of heavy metal toxicity or iron overload, the dosing schedule and medication administered, and the patient's response and follow-up plan. For Medicare members, when the indication does not meet an NCD, local LCD or specific medical policy a PreService Organization Determination (PSOD) must be completed.

Billing guidance notes that CPT 96365 and 96366 are subject to CCI edits and cannot be billed together with injection codes unless properly documented. The appropriate use of modifiers (for example, -59 or the specific X{EPSU} modifiers) may be required to indicate the injection was a separate and distinct service from the infusion. Reimbursement rates are defined in Priority Health's standard fee schedules per contract (login required). The policy origin is Sept 2025 with an effective date of Oct 16, 2025.

Defined Terms

Definitions

PSODPreService Organization Determination required for Medicare when indications do not meet NCD, local LCD or specific medical policy.

Applies toMedicare members when clinical indication is not covered by an NCD, local LCD, or specific medical policy; PSOD must be completed.

Policy origin/effective dateDate of origin Sept 2025; new policy effective Oct 16, 2025 (Policy No. 159).

Related actionPSOD is required in addition to any prior authorization requirements for services such as home infusion per diem (S9355) when Medicare indications are not covered.