CurrentBlue Cross Blue Shield - MassachusettsPolicy 171

Diagnosis and treatment coverage for Lyme disease (testing and antibiotic therapy)

Defines Blue Cross Blue Shield Massachusetts medical policy for diagnostic testing and treatment of Lyme disease for Commercial and Medicare members, including which tests are considered medically necessary, investigational, prior authorization requirements for IV/home infusion therapy, and state-mandated coverage of long-term antibiotic therapy.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyDiagnosis and treatment coverage for Lyme disease (testing and antibiotic therapy)

Policy CodePolicy 171

Change TypeAnnual reviewstate mandate update

Effective Date

Next Review Date

Key ActionObtain prior authorization for inpatient services and complete Home Infusion Therapy Prior Authorization Form #430 for applicable outpatient IV home infusion therapy.

SourceLink

POLICY UPDATE CHANGES

Policy updated to include mandated coverage for repeat or prolonged courses of IV antibiotic therapy effective 10/1/2016 (state mandate).

Clarified coding information.

Annual policy review updated with literature review through August 15, 2024.

Policy statement on short-term IV antibiotic use (2-4 weeks) edited for clarity in 10/2019.

5Covered diagnostic CPT codes listed

4Investigational CPT/U codes listed

3Key PCR/serologic use situations

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