I’m writing in hopes you can direct me as to how to proceed with a difficult case. I’ve attended the chelation coursework and passed the certification exam.
I requested Prior Authorization from Forward Health in Wisconsin for DMSA provoked heavy metal testing. The male patient I work with has worked in the auto repair trade and has had 3 major motor vehicle accidents with surgeries and bolts/plates/screws placed for bone fractures. He has chronic pain requiring opiates, and subsequent functional disability in the context of his history of physical injuries. As he’s not able to afford to pay for chelation therapy, dependent on the lab finding, I would treat for one to three months with an oral herbal preparation. Our goal is to determine if that might improve his pain. It was determined that the heavy metal testing and treatment “did not meet the criterion of medical necessity to qualify for MA reimbursement”.
I then filed a grievance with the legislators because it seems all that is being paid for is ER visits and narcotics. I tried to make the case of potential for reduced costs if treatment is effective. I received a letter back from the State of WI Inspector General saying the over-the-counter herbals aren’t covered. Testing with DMSA provocation is controversial. That the Am. College of Medical Toxicology finds no benefit and it may be harmful to test. He cited UpToDate saying that chelation isn’t supported because there isn’t research to show morbidity and mortality reduction is associated. Their CMS Local Coverage Determination is quoted as medically necessary when the pt has history of likely exposure. They only test with whole blood. And as this pt only has severe, chronic pain, that that is NOT a symptom of heavy metal toxicity, so therefore, testing and treatment are not appropriate and would not be covered.
Do you know of any articles I can reference to Forward Health that explain why I need to do the testing and that it is a valuable test. Are there other arguments to make? Or am I wrong here? I have the articles on the TACT study and the upcoming TACT2 plans, but those speak to heart disease.
Thanks for your input! Sue
Sue Peck PhD, GNP-BC, APNP, FAAO, APT, CHTP/I
Integrative Nurse Practitioner
Fellow American Academy of Ozone Therapy
Health Office Co. at Optima Health & Vitality
3321A Golf Rd.
Eau Claire, WI 54701