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

Note: Please see the following related document for additional information:

• MED.00107 Medical and Other Non-Behavioral Health Related Treatments for Pervasive Developmental Disorders

Medically Necessary:

The administration of U.S. Food and Drug Administration (FDA) approved chelating agents is considered medically necessary treatment in any of the following conditions:

• Individuals with disorders of iron metabolism (e.g., primary or secondary hemochromatosis); or
• Lead overload in cases of acute or long-term lead exposure; or
• Individuals with disorders of copper metabolism (e.g., Wilson's disease); or
• Arsenic, mercury, iron, copper or gold poisoning when long-term exposure thereto and toxicity has been confirmed through lab results (i.e., blood, plasma, or non-challenged urinalysis) or clinical findings (i.e., symptoms consistent with metal toxicity); or
• Aluminum overload in individuals on chronic hemodialysis; or
• Emergency treatment of hypercalcemia.

Investigational and Not Medically Necessary:

Chelation therapy is considered investigational and not medically necessary for the treatment of all other conditions, including but not limited to:

• Alzheimer's disease;
• Autism
• Cadmium exposure;
• Cardiovascular disease (prevention and treatment)
• Chronic fatigue syndrome secondary to dental amalgam therapy;
• Parkinson's disease;
• Peripheral vascular disease;
• Pervasive development disorders (PDD);
• Rheumatoid arthritis.

Chelation therapy can be a safe and effective therapy for conditions where heavy metal overload has been accurately diagnosed. The diagnostic workup must consider the individual's history, an appropriate choice of tests and testing methods, and the use of accurate and specific reference values. With specific regard to urine testing, the diagnosis and use of chelation therapy should not be done based on post-challenge urine testing. In post-challenge, or post-provoked, urine testing, the individual is first given a chelating agent followed by urine testing for heavy metals. The American College of Medical Toxicology (ACMT), in their 2009 position statement on the use of "Post-Chelator Challenge Metal Urine Testing," states that "Scientific investigation to date has failed to establish a valid correlation between prior metal exposure and post-challenge test values" and that post-challenge urine testing is without needed reference values. The ACMT further states the following:

It is therefore, the position of the American College of Medical Toxicology that post-challenge urinary metal testing has not been scientifically validated, has no demonstrated benefit, and may be harmful when applied in the assessment and treatment of patients in whom there is concern for metal poisoning.

With appropriate heavy metal toxicity diagnosis, several studies published in peer-reviewed medical literature have established that chelation therapy can be useful in binding toxic metal ions and facilitating their excretion through the liver or kidneys, mitigating the morbidity associated with heavy metal toxicity such as end organ damage and impaired neurologic functioning.

The role of heavy metal overload in other conditions has not been proven, and thus the role of chelation therapy remains investigational. For example, although chelation therapy has been investigated as a treatment of a wide variety of diseases and conditions, including Alzheimer's disease, Parkinson's, autism, PDD, and rheumatoid arthritis, there has not been adequate scientific evidence to prove the effectiveness and safety of such methods. A meta-analysis by Ng and colleagues (2007) looked specifically at chronic mercury exposure in children and adolescents. The report concluded that there was "no evidence to support the association between mercury poisoning and autism" and "there is a lack of data in the literature about the effect of chelation therapy in children with neuro-developmental disabilities." Further study is needed to ascertain the causal role of heavy metal overload in these conditions, followed by studies demonstrating the efficacy of chelation therapy.

Dental amalgams have been investigated as a cause of increased blood levels of mercury potentially associated with chronic fatigue syndrome or Alzheimer's disease. In 2009, the American Dental Association's Council on Scientific Affairs reviewed the scientific literature on amalgam and stated: "the scientific evidence supports the position that amalgam is a valuable, viable and safe choice for dental patients." The Journal of the American Dental Association (ADA) reported that researchers found "no significant association of Alzheimer's Disease with the number, surface area or history of having dental amalgam restorations" and "no statistically significant differences in brain mercury levels between subjects with Alzheimer's disease and control subjects." The ADA's position has been reaffirmed by the U.S. FDA Center for Devices and Radiological Health in 2002, 2006 and 2009. The ADA's 2010 amalgam safety update cites that "studies continue to support the position that dental amalgam is a safe restorative option for both children and adults."

Chelation therapy has been proposed as a treatment of coronary artery disease, based in part on the hypothesis that chelation could remove atherosclerotic calcium deposits or provide an antioxidant benefit. One small placebo-controlled randomized study of 84 individuals with atherosclerotic heart disease did not report any advantage of chelation therapy, as measured by time to ischemia at 27 weeks of follow up (Anderson, 2003; Knudtson, 2002). The use of chelation therapy in lieu of established therapies, the lack of adequate prior research to verify its safety and effectiveness, and the overall impact of coronary artery disease had prompted the National Center for Complementary and Alternative Medicine (NCCAM) and the National Heart, Lung, and Blood Institute (NHLBI) to sponsor a large-scale study. The 5-year Trial to Assess Chelation Therapy (TACT) in coronary artery disease began recruiting individuals in March of 2003. This multicenter, randomized, double-blind study enrolled more than 1,600 participants aged 50 or older who had a heart attack. The study tested whether chelation therapy or high-dose vitamin therapy are effective for the treatment of coronary artery disease (CAD). The primary study endpoint of this trial was a composite of heart attack, stroke, hospitalization for angina, coronary revascularization, and death. The study also evaluated cardiac deaths, nonfatal heart attacks, health-related quality of life, and cost effectiveness, among other factors. The study has been completed, but study results have not yet been published.

Chelation therapy involves the administration of drugs that bind heavy metal ions such as lead, arsenic, iron, and mercury in the blood stream preventing their interaction with vital organs, which include the nervous system and kidneys. Such drugs are known as chelating agents. The presence of heavy metals in the blood stream can be the result of several factors including environmental exposure, intake in water and food or in some instances such as lead, inhaling the metal from the air in a location where it is in excess. One frequent cause of lead exposure is through older buildings in which lead based paints were used. There are occupational settings where high levels of metals can occur as well. Additionally, many medical conditions may lead to excess iron in the blood stream that may cause health problems. Chelation therapy reduces the accumulation of essential heavy metals, such as iron and copper or nonessential metals, such as lead and aluminum. Chelators bind with heavy metal ions and enhance the urinary and fecal excretion of these toxic metals. 

Chelation therapy has been proposed as a treatment for the removal of heavy metal ions to reduce cellular oxidative damage caused by the production of hydroxyl radicals. This therapy is under investigation for the treatment of numerous non-overload conditions including, but not limited to, cardiovascular disease, reperfusion injury during coronary angioplasty or cardiopulmonary bypass surgery, anthracycline-associated cardiac damage, Alzheimer's disease, Parkinson's disease, autism, PDD, and rheumatoid arthritis.

Chelation agents, however, also have potential toxicity. Chelation agents have been known to bind elements in the body which are necessary for regular functioning, including zinc and calcium. Large doses of vitamins usually accompany the use of chelation agents to lessen these types of side effects. When there is life threatening heavy metal toxicity necessitating treatment with high doses of chelating agents, treatment in the hospital may be needed to monitor for possible side effects. Under less urgent circumstances, chelating agents may be administered on an outpatient basis. Different chelation agents are specific to certain kinds of poisonings.

Primary hemochromatosis: A rare genetic disease that results in the overabundance of iron in the liver, brain, heart and kidneys, causing liver dysfunction, diabetes, changes in skin pigmentation, heart problems, arthritis and testicular atrophy.

Secondary hemochromatosis: A type of hemochromatosis which is usually the result of another condition or disease that causes the overabundance of iron. This disease and condition may include anemias, chronic liver diseases, and the requirement of blood transfusions.

Sickle cell disease: An inherited genetic disorder that causes red blood cells to take on a characteristic crescent or sickle-like shape with decreased ability to carry oxygen.

Sideroblastic anemia: A condition in which there is excess iron in the bone cells.

Thalassemia intermedia: A genetic form of anemia in which there is an abnormality in the oxygen carrying portion of red blood cells.

Wilson's disease: An inherited (autosomal recessive) disorder where excessive quantities of copper build up in the body, particularly in the liver and central nervous system.

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Medically Necessary: 

When services may be Medically Necessary when criteria are met:
For the procedure codes listed above for the following diagnosis codes: 

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Peer Reviewed Publications:

1. Anderson TJ, Hubacek J, Wyse DG, et al. Effect of chelation therapy on endothelial function in patients with coronary artery disease: PATCH study. J Am Coll Cardiol. 2003; 41(3):420-425.
2. Bellinger DC, Trachtenberg F, Barregard L, et al. Neuropsychological and renal effects of dental amalgam in children: a randomized clinical trial. JAMA. 2006: 295(25): 1775-1783.
3. Cohen AR, Martin MB. Iron chelation therapy in sickle cell disease. Semin Hematol. 2001; 38(1Suppl1):69-72.
4. Franchini M, Gandini G, de Gironcoli M, et al. Safety and efficacy of subcutaneous bolus injection of deferoxamine in adult patients with iron overload. Blood. 2000; 95(9):2776-2779.
5. Guha Mazumder DN, De BK, Santra A, et al. Randomized placebo-controlled trial of 2,3-dimercapto-1-propanesulfonate (DMPS) in therapy of chronic arsenicosis due to drinking arsenic-contaminated water. J Toxicol Clin Toxicol. 2001; 39(7):665-674.
6. Knudtson ML, Wyse DG, Galbraith PD, et al. Chelation therapy for ischemic heart disease: A randomized controlled trial. JAMA. 2002; 287(4):481-486.
7. Ng DK, Chan CH, Soo MT, Lee RS. Low-level chronic mercury exposure in children and adolescents: meta-analysis. Pediatr Int. 2007; 49(1):80-87.
8. Rogan WJ. Safety and efficacy of succimer in toddlers with blood lead levels of 20-44 microg/dL. Treatment of lead-exposed children (TLC) trial group. Pediatr Res. 2000; 48(5):593-599.
9. Rogan WJ, Dietrich KN, Ware JH, et al. The effect of chelation therapy with succimer on neuropsychological development in children exposed to lead. N Engl J Med. 2001; 344(19):1421-1426.
10. Rombos Y, Tzanetea R, Konstantopoulos K, et al. Chelation therapy in patients with thalassemia using the orally active iron chelator deferiprone (L1). Haematologica. 2000; 85(2):115-117.
11. Shimizu N, Yamaguchi Y, Aoki T. Treatment and management of Wilson's disease. Pediatr Int. 1999; 41(4):419-422.
12. Waters RS, Bryden NA, Patterson KY, et al. EDTA chelation effects on urinary losses of cadmium, calcium, chromium, cobalt, copper, lead, magnesium, and zinc. Biol Trace Elem Res. 2001; 83(3):207-221.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Pediatrics. Policy Statement. Lead exposure in children: prevention, detection, and management. Pediatrics. 2005; 116(4): 1036-1046.
2. American College of Medical Toxicology. Position Statement. Post-chelator challenge urinary metal testing. 2009. Available at: http://www.acmt.net/cgi/page.cgi/zine_service.html?aid=2999&zine=show. Accessed on January16, 2013.
3. American Dental Association. Amalgam safety update. September 2010. Available at: http://www.ada.org/sections/professionalResources/pdfs/amalgam_literature_review_1009.pdf. Accessed on January 11, 2013.
4. American Dental Association. Statement on Dental Amalgam. ADA council on scientific affairs. Revised August 2009. Available at: http://www.ada.org/1741.aspx. Accessed on January 11, 2013.
5. Centers for Medicare and Medicaid Services. Available at: http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed on January 11, 2013.
   • National Coverage Determination: Chelation Therapy for Treatment of Atherosclerosis. NCD #20.21. Effective date not posted
   • National Coverage Determination: Ethylenediamine-Tetra-Acetic (EDTA) Chelation Therapy for Treatment of Atherosclerosis. NCD #20.22. Effective date not posted
6. Dans AL, Tan FN, Villarruz-Sulit EC. Chelation therapy for atherosclerotic cardiovascular disease. Cochrane Database Syst Rev. 2002 (4):CD002785.
7. Sampson EL, Jenagaratnam L, McShane R. Metal protein attenuating compounds for the treatment of Alzheimer's disease. Cochrane Database Syst Rev. 2008 (1):CD005380.

1. National Heart, Lung, and Blood Institute. Disease and Conditions Index, Blood Diseases. Thalassemia. Revised July 2012. Available at: http://www.nhlbi.nih.gov/health/dci/Browse/Blood.html. Accessed on December 21, 2012.
2. U.S. Food and Drug Administration Center for Devices and Radiological Health (CDRH). CDRH consumer information. Dental amalgams. Updated July 28, 2009. Rockville, MD: FDA. Available at: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DentalProducts/DentalAmalgam/default.htm. Accessed on December 21, 2012.

Autism
BAL
Calcium disodium Versenate^®
Calcium EDTA
CaNa2-EDTA
Cooley's anemia
Deferoxamine mesylate
Desferal^®
Desferrioxamine
Dimercaprol
Disodium EDTA
DMSA
Edathamil calcium disodium
Edathamil disodium
Edetate calcium disodium
Hemochromatosis
Pervasive Development Disorders
Sodium calcium EDTA
Wilson's Disease

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.