dimercaptosuccinic acid — Medica

Initial criteria

• Patient has a diagnosis of lead poisoning, mercury poisoning, or arsenic poisoning
• AND requested indication is consistent with FDA-approved or evidence-based use for heavy metal chelation (arsenic, lead, mercury)
• AND not used for any non-covered circumstances (e.g., autism or conditions not related to heavy metal toxicity)

Reauthorization criteria

• Patient continues to meet initial authorization criteria
• AND clinical benefit from therapy is demonstrated or ongoing heavy metal exposure risk persists

Approval duration

1 course (up to 19 days) or 1 month, as clinically appropriate