ModifiedAmbetter NevadaPolicy N/A

Vector-borne and tropical diseases laboratory testing: Lyme disease and Zika virus (coverage criteria)

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Outpatient coverage criteria for serologic and molecular laboratory testing for Lyme disease (Borrelia burgdorferi) and Zika virus, including which tests are medically necessary or not; intended for providers ordering and billing for Ambetter Nevada members.

Policy Summary

PayerAmbetter Nevada

PolicyVector-borne and tropical diseases laboratory testing: Lyme disease and Zika virus (coverage criteria)

Policy CodePolicy N/A

Change TypeModified clinical criteria wording and coding table location

Effective DateN/A

Last ReviewNov 24, 2024

Next Review DateN/A

Key ActionOrder Lyme serology only when there is plausible exposure PLUS an indicated clinical syndrome; prefer two-tier serology over PCR except for synovial fluid in seropositive patients.

SourceLink

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ModifiedAmbetter NevadaPolicy N/A

Vector-borne and tropical diseases laboratory testing: Lyme disease and Zika virus (coverage criteria)

Customize your policy alerts

Sign up for all Ambetter Nevada policy alerts

Know when Ambetter Nevada releases new policies or updates existing guidance.

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Policy Summary

PayerAmbetter Nevada

PolicyVector-borne and tropical diseases laboratory testing: Lyme disease and Zika virus (coverage criteria)

Policy CodePolicy N/A

Change TypeModified clinical criteria wording and coding table location

Effective DateN/A

Last ReviewNov 24, 2024

Next Review DateN/A

Key ActionOrder Lyme serology only when there is plausible exposure PLUS an indicated clinical syndrome; prefer two-tier serology over PCR except for synovial fluid in seropositive patients.

SourceLink

POLICY UPDATE CHANGES

Reworded policy statements from 'may be considered medically necessary' to 'are considered medically necessary' for criteria sections covering Lyme and Zika testing.

Removed CPT and ICD-10 codes from the policy reference table and added a CPT code table in the coding implications section.

2diseases covered (Lyme, Zika)

4Lyme serology indications listed as medically necessary

3Zika testing medically necessary populations

6CPT codes listed in policy

3reference items

Coverage Criteria — Lyme Disease and Zika Virus Testing

Lyme Disease (Borrelia burgdorferi) Serum Antibody Tests

Covered when ALL of the following are met

Lyme serology general: Member had a plausible exposure to Borrelia burgdorferi

Exposure includes geographic/epidemiologic risk

Clinical indications: Member has at least one of: (1) skin lesion(s) suggestive of but atypical for erythema migrans; (2) suspected Lyme neuroborreliosis involving peripheral or central nervous system; (3) suspected Lyme arthritis; (4) acute myocarditis or pericarditis

Lyme Disease (Borrelia burgdorferi) Nucleic Acid/PCR Tests

Covered when ALL of the following are met

Lyme PCR general: Member is seropositive for Lyme disease

Seropositive by standard serology

Clinical indication: Member is suspected of Lyme arthritis

Purpose: Testing is necessary for making treatment decisions

PCR on synovial fluid/tissue is recommended by joint society guidance in seropositive patients when treatment decisions require more definitive information

Other Non-covered Lyme Disease Tests

Non-covered Lyme tests: Lymphocyte transformation tests; Lyme Borrelia Nanotrap Urine Antigen Test; Lyme ImmunoBlot IgG; Lyme ImmunoBlot IgM

These specific tests lack reproducible validation and are not supported

Zika Virus Nucleic Acid/PCR Tests

Covered when ANY of the following are met

Pregnant individual with plausible exposure: Member is pregnant AND had a plausible exposure to Zika virus (e.g., travel to or residence in an area with transmission or sexual exposure to someone with such travel/residence)

Testing recommended for pregnant persons with exposure

Infant criteria A: Member is 12 months of age or younger AND the mother had laboratory evidence of Zika virus infection during pregnancy

Infant criteria B: Member is 12 months of age or younger AND has symptoms of congenital Zika virus infection AND the child's mother had a plausible exposure to Zika virus

Zika Virus Antibody Tests

Covered when ANY of the following are met

Pregnant with ultrasound findings: Member is pregnant AND prenatal ultrasound findings consistent with congenital Zika virus infection (e.g., microcephaly, ventriculomegaly, or corpus callosum abnormalities) AND had a plausible exposure to Zika virus

Examples: microcephaly, ventriculomegaly, corpus callosum abnormalities

Infant maternal-lab-evidence: Member is 12 months of age or younger AND the mother had laboratory evidence of Zika virus infection during pregnancy

Infant with congenital symptoms and maternal exposure: Member is 12 months of age or younger AND has symptoms of congenital Zika virus infection AND the mother had a plausible exposure to Zika virus

The policy lists specific circumstances in which Lyme disease serum antibody testing is considered medically necessary and also identifies explicit exclusions. Serum antibody testing is medically necessary only when the member had a plausible exposure to Borrelia burgdorferi and the member presents with at least one of the following: (1) a skin lesion suggestive of but atypical for erythema migrans, (2) suspected Lyme neuroborreliosis (peripheral or central nervous system involvement), (3) suspected Lyme arthritis, or (4) acute myocarditis/pericarditis. Conversely, testing is not supported for a range of other indications including asymptomatic patients after a tick bite, classic erythema migrans, typical neurodegenerative disorders (e.g., ALS, multiple sclerosis, Parkinson’s), dementia/cognitive decline, new-onset seizures, nonspecific MRI white-matter findings confined to the brain, psychiatric illness, developmental or behavioral disorders in children, and chronic cardiomyopathy of unknown cause.

When state Medicaid coverage provisions conflict with this clinical policy, the state Medicaid provisions take precedence. Providers should refer to the applicable state Medicaid manual and the member’s coverage documents for the controlling rules, since this clinical policy is a guide to medical necessity and does not supersede contractual, statutory, or regulatory requirements.

The policy explicitly identifies several Lyme testing modalities that are not supported due to lack of independent, reproducible validation. These include lymphocyte transformation tests, the Lyme Borrelia Nanotrap urine antigen test, and certain commercial ImmunoBlot methods (listed as Lyme ImmunoBlot IgG and Lyme ImmunoBlot IgM). In addition, the policy references guideline language advising avoidance of nonstandard serology interpretation, urine antigen, DNA testing alternatives, and quantitative CD57 lymphocyte assays for clinical use because they lack systematic validation.

Provider Actions, Documentation, and Billing Guidance

Prior Authorization

Prior authorization may apply for referenced CPT/HCPCS codes

Certain CPT/HCPCS codes referenced in the policy's coding table may require prior authorization per payer processes when coverage criteria are not clearly met.

Referenced codes include 0041U, 0042U, 0316U, 86617, 86618, 86794, 87475, 87476, 87662.

Prior Authorization

No specific prior authorization rules stated

No specific prior authorization requirements are specified in these policy chunks.

Step Therapy

Preferred testing sequence for Lyme disease

Follow the preferred testing sequence: two‑tier serologic testing is recommended over PCR/culture in most clinical scenarios; PCR on synovial fluid is recommended only for seropositive patients when PCR is needed to inform treatment decisions.

Coding Implications and CPT References

Referenced CPT codesCPT

0041U	Borrelia burgdorferi, antibody detection of 5 recombinant protein groups, by immunoblot, IgM
0042U	Borrelia burgdorferi, antibody detection of 12 recombinant protein groups, by immunoblot, IgG
0316U	Borrelia burgdorferi (Lyme disease), OspA protein evaluation, urine
86617	Antibody; Borrelia burgdorferi (Lyme disease) confirmatory test (eg, Western Blot or immunoblot)
86618	Antibody; Borrelia burgdorferi (Lyme disease)
86794	Antibody; Zika virus, IgM
87475	Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, direct probe technique
87476	Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, amplified probe technique
87662	Infectious agent detection by nucleic acid (DNA or RNA); Zika virus, amplified probe technique

Definitions and Background

inv-19: Lyme neuroborreliosis — definition and clinical examples

DefinitionLyme neuroborreliosis: cranial or peripheral nerve involvement (e.g., facial palsy, radiculoneuropathy) or central nervous system involvement (meningitis/encephalitis).

Common clinical examplesFacial (VII) palsy presenting after possible tick exposure

Other presentationsRadiculoneuropathy causing limb pain/weakness; lymphocytic meningitis or encephalitis with compatible exposure history

Documentation tipClinical signs of cranial/peripheral nerve dysfunction or CNS infection should be documented along with plausible exposure history

inv-20: Lyme arthritis — definition

DefinitionLyme arthritis: obvious swelling of one or more joints with joint pain on movement.

Policy Summary

PayerAmbetter Nevada

PolicyVector-borne and tropical diseases laboratory testing: Lyme disease and Zika virus (coverage criteria)

Policy CodePolicy N/A

Change TypeModified clinical criteria wording and coding table location

Effective DateN/A

Last ReviewNov 24, 2024

Next Review DateN/A

Key ActionOrder Lyme serology only when there is plausible exposure PLUS an indicated clinical syndrome; prefer two-tier serology over PCR except for synovial fluid in seropositive patients.

SourceLink

On This Page

IDSA/AAN/ACR recommend serum antibody testing over PCR or culture in most scenarios (guideline reference).
PCR on synovial fluid/tissue is recommended for seropositive patients when diagnosis/treatment decisions require more definitive information.

Step Therapy

No step therapy requirements specified

No step therapy requirements are specified in the policy chunks provided.

Documentation Required

Required clinical documentation to support testing

Document a plausible exposure and the specific clinical syndrome and timing to support testing; for Lyme PCR on synovial fluid, document seropositive status when testing to guide treatment decisions.

Plausible exposure: geographic/epidemiologic risk, travel, or sexual exposure (for Zika).
Clinical syndrome examples: atypical erythema migrans, neuroborreliosis signs, Lyme arthritis, myocarditis/pericarditis, prenatal ultrasound findings consistent with congenital Zika, or infant congenital symptoms.
For Lyme PCR on synovial fluid, document that the member is seropositive by standard serology.

Note

Provider responsibilities and policy limits

Providers must exercise professional medical judgment; this clinical policy is a guide to medical necessity and does not guarantee payment or replace provider judgment.

The policy does not constitute medical advice or dictate clinical practice; providers are solely responsible for medical care.
Coverage decisions remain subject to contract terms, exclusions, limitations, and applicable legal/regulatory requirements.

Denial Risk

Denial risk for tests ordered for unsupported indications

Tests performed for indications explicitly listed as not supported by current evidence may be denied.

Examples include: asymptomatic patients following tick bite; erythema migrans; routine screening (pre-conception/prenatal); symptomatic non‑pregnant persons for Zika; and use of specified non‑covered Lyme tests (e.g., lymphocyte transformation tests, urine antigen tests).

Note

Coverage subject to plan terms, exclusions, and legal requirements

Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the member's coverage documents and applicable state/federal requirements.

For Medicaid members, state Medicaid provisions take precedence when they conflict with this clinical policy.

Typical findingMarked monoarticular swelling (commonly knee) often with intermittent pain exacerbated by movement

Clinical noteDocument joint swelling and pain with movement plus plausible exposure to Borrelia burgdorferi

inv-21: Congenital Zika virus infection — definition and typical findings

DefinitionCongenital Zika virus infection: a syndrome characterized by severe microcephaly (sometimes with craniofacial bone malformations), decreased brain tissue with specific patterns of damage including subcortical calcifications, and ocular damage (macular scarring, focal retinal pigmentary mottling).

Other typical findingsCongenital contractures (e.g., clubfoot or arthrogryposis) and hypertonia or stiff/rigid posture with restricted movement

Clinical implicationPrenatal ultrasound findings consistent with these features or infant congenital symptoms plus maternal exposure support testing per policy

inv-22: Lyme disease guideline reference — IDSA/AAN/ACR 2020 guideline citation

CitationLantos PM, Rumbaugh J, Bockenstedt LK, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America, American Academy of Neurology, and American College of Rheumatology: 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease. Neurology. 2021 Feb 9;96(6):262-273. doi:10.1212/WNL.0000000000011151.

PublishedEpub 2020 Nov 30; print 2021 Feb 9

ContextGuideline cited in policy to support recommendations on serology and PCR testing for Lyme disease

inv-23: CDC Zika/Dengue testing guidance — CDC web guidance citations

Testing guidance (general)Testing for Zika. Centers for Disease Control and Prevention. May 15, 2024. Accessed November 08, 2024. https://www.cdc.gov/zika/testing/

Zika/Dengue comparative guidanceZika and Dengue Testing Guidance. Centers for Disease Control and Prevention. May 15, 2024. Accessed November 08, 2024. https://www.cdc.gov/zika/hc-providers/testingguidance.html.

UsageCDC web guidance cited in policy to define indications and testing recommendations for pregnant persons and infants

Vector-borne infections covered by this policy (Lyme disease and Zika virus) are transmitted by arthropod vectors—ticks for Borrelia burgdorferi and mosquitoes (or sexual exposure following travel) for Zika virus—and the likelihood of exposure is influenced by geography, seasonality, and travel history. The policy requires documentation of a plausible exposure (for example, residence in or travel to an area with documented transmission or sexual contact with someone from such an area) as part of medical necessity determinations. For Lyme disease, testing is centered on compatible clinical syndromes (skin lesion atypical for erythema migrans, neurologic involvement, arthritis, or myocarditis/pericarditis). For Zika virus, testing criteria focus on pregnant persons or infants ≤12 months with maternal laboratory evidence or congenital findings—consistent with CDC guidance that routine screening of asymptomatic persons is not recommended and that testing decisions should account for travel/exposure and prenatal imaging findings.