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 review; state 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.

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

Overview: This policy defines Blue Cross Blue Shield Massachusetts coverage for diagnosis and treatment of Lyme disease, including which diagnostic tests and antibiotic therapies are considered medically necessary, investigational, and subject to prior authorization. Coverage stance is mixed — some diagnostic tests and short-term IV therapy are covered when medically necessary, while prolonged/repeat antibiotic courses and several nonstandard tests are investigational. The policy reflects the impact of the Massachusetts state mandate (Chapter 183, Section 12DD) which requires coverage for long-term antibiotic therapy (>4 weeks) when determined medically necessary and ordered by a licensed physician. Effective/last review dates and policy history note annual reviews with literature updated through August 15, 2024 and the most recent last_review date of 2024-10-01.

Surface thresholds and quick-reference items

Duration of neurologic symptoms for PCR utility< 14 days

Short-term IV antibiotic duration2-4 weeks

Long-term antibiotic therapy definition> 4 weeks

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

Policy number / status / last reviewPolicy #171 — CURRENT; Last review: 2024-10-01

OpenPayer

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

Coverage Summary