Certificate of Medical Necessity:
Chelation Therapy
Edetate calcium disodium, Ethylenediamine tetraacetic acid (EDTA),
Dimercaprol, Deferoxamine mesylate
For Pre-Service: Statewide Fax (877) 219-9448
Fax or mail this
completed form
For Medicare Advantage (BlueMedicare) HMO and PPO Plans: Fax (904) 301-1614
to:
For Post-Service Claims:
Florida Blue
P.O. Box 1798
Jacksonville, FL 32231-0014
Section A
Physician Information/
Requesting Provider
Name:
BCBSF No:
Contact Name:
Facility Information/
Location where services
will be rendered
Member Information
Procedure Information
National Provider Identifier (NPI):
Phone:
Name:
BCBSF No:
National Provider Identifier (NPI):
Contact Name:
Phone:
Last Name:
First Name:
Member/Contract Number (alpha and numeric):
Date of Birth:
Procedure Code(s):
Procedure Description:
Diagnosis code(s):
Diagnosis Description:
Date of Service/Tentative Date:
Section B
Medical Necessity:
For detailed information on chelation therapy including the criteria that meet the definition of medical necessity, visit
the Florida Blue Medical Coverage Guideline website at http://mcgs.bcbsfl.com. Refer to Medical Coverage
Guideline 01-99000-07, Chelation Therapy (Edetate calcium disodium, Ethylenediamine tetraacetic acid (EDTA),
Dimercaprol, Deferoxamine mesylate.) For Medicare members, refer to Local Coverage Determination (LCD)
CHELATION Therapy (L29098) for more information.
Section C
Complete ALL entries in this section:
Is chelation therapy being administered for the treatment the following?
Yes
No
Extreme conditions of metal (arsenic, mercury, lead, cadmium) toxicity, including thalassemia intermedia with
hemosiderosis
Yes
No
Wilson’s disease (hepatolenticular degeneration)
Yes
No
Lead poisoning
Yes
No
Acute iron intoxication and chronic iron overload due to transfusion-dependent anemias
Yes
No
Emergency treatment of hypercalcemia
Yes
No
Control of ventricular arrhythmias or heart block associated with digitalis toxicity
Yes
No
Other indications
List and describe:
Certificate of Medical Necessity: Chelation Therapy
CMN01-99000-07_021014
1
Section D – Medicare Members
Yes
No
Is chelation therapy being administered for diseases/disorders?
Check all that apply:
Yes
No
Yes
No
cystinuria
Yes
No
secondary hematochromatosis (due to iron overload from multiple transfusions)
Yes
No
Wilson’s disease
Yes
No
Other
Describe:
Is chelation therapy being administered for heavy metal poisoning?
Check all that apply:
Yes
No
Arsenic, cadmium, copper, gold, iron, lead, or mercury
Yes
No
Specific signs and symptoms of heavy metal toxicity
Yes
No
A history of likely exposure to heavy metals with standard of care laboratory confirmation
Yes
No
Other
Describe:
Dimercaprol (BAL) (procedure code J0470)
Yes
No
Is Dimercaprol (BAL) being used as an antidote in arsenic, mercury, lead, and cadmium poisoning?
Edetate Calcium Disodium (Calcium EDTA) (procedure code J0600)
Yes
No
Is Edetate Calcium Disodium (Calcium EDTA) being used as an antidote in lead poisoning and lead
encephalopathy?
Deferoxamine Mesylate (Desferal) (procedure code J0895)
Yes
No
Is Deferoxamine mesylate (Desferal) being used to treat iron poisoning?
Yes
No
Is Desferal being used for the treatment of acute iron intoxication and of chronic iron overload due to transfusiondependent anemias?
Additional Comments:
I hereby certify that (i) I am the treating physician for above member, (ii) the information contained in and included with this Certificate of Medical Necessity is true, accurate and
complete to the best of my knowledge and belief, (iii) the member’s medical records contain all appropriate documentation necessary to substantiate this information. I acknowledge
that a determination made based upon this Certificate of Medical Necessity is not necessarily a guarantee of payment and that payment remains subject to application of the
provisions of the member’s health benefit plan, including eligibility and plan benefits. Additionally, I further acknowledge and agree that Florida Blue may audit or review the underlying
medical records at any time and that failure to comply with such request may be a basis for the denial of a claim associated with such services.
Ordering Physician’s Signature:
Certificate of Medical Necessity: Chelation Therapy
Date:
2