Lyme Disease Testing
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Defines Blue Cross Blue Shield Illinois reimbursement and coverage criteria for laboratory testing to diagnose Lyme disease, including serologic and PCR-based tests, and specifies situations where testing is reimbursable or not; applies to providers submitting claims to BCBSIL.
New policy created specifying reimbursable and non-reimbursable Lyme disease tests and clinical indications.
Coverage Criteria for Lyme Disease Testing
Medically necessary/reimbursable testing
Serologic testing and PCR detection are reimbursable when clinical criteria are met as follows.
From Reimbursement Information item 1.
From Reimbursement Information item 2 (a–e).
From Reimbursement Information item 4.
Not reimbursable testing
Testing not reimbursable in the following explicit situations.
From Reimbursement Information items 5–7.
The policy explicitly excludes several specific testing scenarios from reimbursement. Testing of ticks for the diagnosis of Lyme disease is not covered. Repeat serologic testing after an individual has previously tested positive is not reimbursable. Additionally, any Borrelia burgdorferi testing methods not described in this policy are excluded from reimbursement. Providers should confirm that the ordered test and method are described and supported by the policy before submitting claims.
Serologic testing follows a two-tier strategy (sensitive EIA or IFA followed by western immunoblot or an FDA-cleared second EIA) and is intended to support clinical assessment rather than replace it. Serologic testing is not reimbursable for individuals with an erythema migrans (EM) rash because such patients in endemic areas should be treated clinically without need for serologic confirmation. The policy also designates serologic testing as not medically necessary for asymptomatic screening of patients living in endemic areas and for evaluation of non-specific symptoms only (for example, fatigue, myalgias, or arthralgias). These exclusions reflect the limited diagnostic value of serology in those settings and the primacy of clinical judgment for typical EM presentations.
Clinical Indications That Warrant Testing
Symptomatic individuals; covered indications
Symptomatic individuals with travel to endemic region; certain neurologic or cardiac presentations. Two-tier serology required; PCR on CSF may be used for early neurologic symptoms <14 days.
From Reimbursement Information item 1.
From Reimbursement Information item 2 (a–e).
From Reimbursement Information item 4; PCR may replace serology during early window.
Procedure and Billing Codes
Provider Responsibilities and Billing Guidance
Plan-dependent coverage — verify benefits before ordering
Coverage varies by product — always confirm member eligibility and specific benefit terms before ordering or billing. Plan documents (Certificates, benefit booklets, Summary Plan Descriptions, etc.) and applicable provider contracts govern coverage when conflicts arise; providers must follow those documents over this policy when discrepancies exist.
- Check member-specific plan documents for lab management and reimbursement criteria prior to ordering.
- When a plan document or provider contract conflicts with this policy, the plan document or contract governs.
Denial risk for non-covered indications or tests
Claims for Lyme disease testing may be denied when testing is performed for indications that the Plan considers non-reimbursable. Providers should confirm medical necessity and coverage criteria prior to testing to reduce denials.
- Serologic testing is not reimbursable for erythema migrans (EM) rash — treat clinically instead of testing.
- Testing to screen asymptomatic individuals in endemic areas or for non-specific symptoms (e.g., fatigue, myalgias/arthralgias) is not reimbursable.
- Repeat serologic testing after a prior positive result is not reimbursable.
- All other Borrelia burgdorferi tests not described as reimbursable in this policy are not reimbursable, including testing of the tick.
Clinical indication and documentation required
Providers must document the clinical indication and supporting information when submitting claims for Lyme disease testing. Include symptoms, travel/residence history, exposure risk, and any relevant clinical findings to establish medical necessity.
- Document symptomatic status and travel or residence in an endemic region when applicable.
- For neurologic presentations, document symptom onset timing (e.g., <14 days) when considering PCR on CSF.
- Retain and provide additional documentation upon request (e.g., medical records, clinician notes).
Two-tier serologic testing requirement
Reimbursement follows a two-tier serologic testing strategy: perform a sensitive EIA or IFA as the initial assay, and confirm positives with a Western immunoblot or an FDA-cleared second EIA. This two-tier approach must be followed for serologic testing to be considered for reimbursement.
- Initial testing: sensitive EIA or immunofluorescence assay (IFA).
- Confirmatory testing: Western immunoblot assay or FDA-cleared second EIA.
- For certain neurologic presentations with symptom duration <14 days, PCR testing of CSF may be reimbursable and can replace serology.
Definitions
Limits on Repeat Testing
Services Not Covered
The policy lists several situations and methods that are not covered. Testing of the tick itself to diagnose Lyme disease is not reimbursable. Repeat serologic testing after a prior positive test is not covered. The policy further states that all other testing for Borrelia burgdorferi not described in the reimbursement section is not reimbursable. Consistent with the exclusions for serology, serologic testing for individuals with erythema migrans, asymptomatic screening in endemic areas, and testing for non-specific symptoms alone are not eligible for reimbursement.
Background and Clinical Context
Lyme disease diagnosis is primarily clinical and laboratory tests are used to support, not replace, clinical assessment. The policy requires two-tier serologic testing (a sensitive enzyme immunoassay or immunofluorescence assay followed by western immunoblot or an FDA-cleared second EIA) when serology is indicated. For patients with early neurologic manifestations, the policy allows PCR-based direct detection of B. burgdorferi in CSF as a reimbursable alternative when performed within a short window: <14 days from symptom onset, before antibodies are reliably detectable. Providers should document clinical signs, travel or residence in endemic areas, and symptom duration when ordering tests.
Policy Revision History
New Lyme disease laboratory testing policy (CPCPLAB044) became effective specifying reimbursable and non-reimbursable tests and clinical indications.
Policy version 1.0 approved on September 5, 2025.
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