Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesLaboratory/PathologyBlue Cross Blue Shield NM Lyme Testing Coverage Up…
    Ask Trek AI about this page
    CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB044

    Lyme Disease Testing

    Customize your policy alerts

    Sign up for Blue Cross Blue Shield - New Mexico Policy CPCPLAB044 alerts

    Get alerted when Policy CPCPLAB044 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Laboratory reimbursement and coverage criteria for diagnostic testing for Lyme disease for Blue Cross Blue Shield of New Mexico members and participating providers.

    Policy Summary
    PayerBlue Cross Blue Shield - New Mexico
    PolicyLyme Disease Testing
    Policy CodePolicy CPCPLAB044
    Change TypeAdded codeclarified reimbursement language
    Effective DateAug 1, 2025
    Last ReviewAug 1, 2025
    Next Review Date
    Key ActionVerify product-level coverage and prior authorization requirements before ordering Lyme testing.
    SourceLink
    POLICY UPDATE CHANGES

    Added code 0580U effective 10/01/2025.

    Reimbursement information revised for clarity (11/01/2023) and literature review updates (2024 and 2025) with reimbursement information unchanged in 2024 update.

    7

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    procedure/test codes listed
    2-tierrecommended serologic testing strategy
    14 daysPCR utility window (CSF)
    notick testing reimbursable?

    Coverage Criteria for Lyme Disease Testing

    inv-01: Medically necessary indications

    Covered when ANY of the following clinical scenarios are met:

    Serologic testing for symptomatic individuals with endemic exposure: Serologic testing using a 2-tier strategy (sensitive EIA/IFA followed by Western immunoblot or FDA-cleared second EIA) may be reimbursable for individuals with symptoms of Lyme disease and a history of travel to a Lyme-endemic region (with or without a known tick bite).

    [[chunk 3]]

    Serologic testing for selected cardiac and neurologic presentations: For individuals with travel to an endemic region, serologic testing may be reimbursable for acute myocarditis or pericarditis of unknown cause; meningitis, encephalitis, or myelitis; painful radiculoneuritis; mononeuropathy multiplex (including confluent); or acute cranial neuropathy.

    [[chunk 3]]

    PCR in early neurologic disease (CSF): Polymerase chain reaction (PCR)-based direct detection of B. burgdorferi in CSF may be reimbursable and may replace serologic testing in patients with a short duration of neurologic symptoms during the seroconversion window.<14 days symptom duration

    [[chunk 4]]

    inv-02: Not reimbursable / Exclusions

    Not reimbursable (explicit exclusions):

    Erythema migrans (EM): Serologic testing is not reimbursable for individuals with an erythema migrans rash; patients with EM who reside in or recently traveled to an endemic area should be treated for Lyme disease.

    [[chunk 3]]

    Asymptomatic screening: Serologic testing to screen asymptomatic patients living in endemic areas is not reimbursable.

    [[chunk 3]]

    Non-specific symptoms only: Serologic testing for individuals with only non-specific symptoms (e.g., fatigue, myalgias/arthralgias) is not reimbursable.

    [[chunk 3]]

    Specific neurologic/neurologic-mimic and neurodegenerative exclusions: Testing is not reimbursable for individuals with amyotrophic lateral sclerosis, relapsing-remitting multiple sclerosis, Parkinson's disease, dementia or cognitive decline, new-onset seizures, or psychiatric illness.

    Testing of a removed tick for the diagnosis of Lyme disease is not reimbursable. Claims for tests performed on the vector (the tick) will be denied and should not be submitted for Blue Cross Blue Shield of New Mexico members.

    Serologic testing for Lyme disease is not reimbursable in several scenarios: screening asymptomatic patients who live in or travel to endemic areas; testing individuals with an erythema migrans (EM) rash (these patients should be treated for Lyme disease rather than serologically tested); and testing for individuals with only non‑specific symptoms (for example, fatigue or myalgias/arthralgias).

    Additional exclusions include testing for patients with certain neurologic or neurodegenerative conditions or psychiatric illness (examples listed: amyotrophic lateral sclerosis, relapsing‑remitting multiple sclerosis, Parkinson’s disease, dementia or cognitive decline, or new‑onset seizures). Repeat serologic testing after a prior positive test and any other Borrelia burgdorferi tests not described in this policy are also not reimbursable.

    Specific Covered Indications

    inv-11: Symptomatic individuals with travel to endemic regions; selected neurologic and cardiac presentations; early neurologic disease — CSF PCR utility (<14 days)

    Covered when ANY of the following clinical scenarios are met:

    Symptomatic individuals with travel to endemic regions: Serologic testing using a 2-tier strategy is reimbursable for individuals with symptoms of Lyme disease and a history of travel to a Lyme-endemic region (with or without a known tick bite).

    [[chunk 3]]

    Selected neurologic and cardiac presentations: For individuals with travel to an endemic region, serologic testing may be reimbursable for acute myocarditis/pericarditis of unknown cause; meningitis, encephalitis, or myelitis; painful radiculoneuritis; mononeuropathy multiplex (including confluent); or acute cranial neuropathy.

    [[chunk 3]]

    Early neurologic disease—CSF PCR utility: PCR-based direct detection of B. burgdorferi in CSF may be reimbursable and can replace serology in patients with short-duration neurologic symptoms during the window before detectable antibodies develop.

    Procedure and Test Codes

    Listed procedure/test codesmixed
    86617Lyme disease antibody; screening immunoassay
    86618Lyme disease antibody; confirmatory, immunoblot
    87475Infectious agent detection by nucleic acid (e.g., PCR) for Borrelia burgdorferi
    87476Infectious agent detection by nucleic acid; different specimen or additional target (as listed)
    0041UProprietary Lyme disease test (as listed)
    0042UProprietary Lyme disease test (as listed)
    0316UProprietary Lyme disease test (as listed)
    0580UProprietary Lyme disease test (added effective 10/01/2025)

    Provider Actions and Documentation Requirements

    Documentation Required

    Clinical documentation requirement

    Providers are responsible for submission of accurate clinical documentation that supports the medical necessity of Lyme disease testing. Upon request, submit additional records (history, signs/symptoms, travel to endemic area, exposure/tick bite, onset and duration of symptoms, diagnostic test results, and relevant consult notes). Claims are subject to review against plan benefits, provider contract language, coding policies, and coding edits; lack of adequate documentation may result in denial or request for more information.

    • Include travel history to Lyme-endemic regions or documented exposure when applicable.
    • Document specific signs/symptoms (e.g., erythema migrans, meningitis, radiculoneuritis, cranial neuropathy, myocarditis/pericarditis) and symptom duration.
    • When ordering serologic testing, document use of a 2-tier testing strategy and prior test results if relevant.
    Prior Authorization

    Check product-level coverage / prior authorization

    Not Covered Services

    The following testing scenarios are explicitly not covered / not reimbursable: serologic testing to screen asymptomatic individuals in endemic areas; serologic testing for persons with erythema migrans (EM) rash; serologic testing when only non‑specific symptoms are present (e.g., fatigue, myalgias/arthralgias); serologic testing for listed neurologic/neurodegenerative or psychiatric conditions (amyotrophic lateral sclerosis, relapsing‑remitting multiple sclerosis, Parkinson’s disease, dementia/cognitive decline, new‑onset seizures, psychiatric illness); repeat serologic testing after a prior positive result; testing of a removed tick for diagnosis of Lyme disease; and any other Borrelia burgdorferi tests not described by this policy.

    Providers should order Lyme testing only when the clinical indications described in the policy are met and should expect claims for the above scenarios to be denied.

    Frequency and Repeat Testing

    Repeat serologic testing after prior positive result
    Policy frequency ruleRepeat serologic testing after a prior positive Lyme disease test is not reimbursable (no repeat serology)
    ScopeApplies to serologic Lyme testing procedures described in this policy (two-tier serology and other listed Borrelia tests)
    Provider actionDo not order repeat antibody serology for members with a documented prior positive Lyme test unless policy or clinical context explicitly supports retesting

    Definitions and Testing Strategies

    Two-tier testing (definition and recommended strategy)
    DefinitionTwo-tier testing: initial sensitive enzyme immunoassay (EIA) or immunofluorescence assay (IFA) followed by a Western immunoblot OR an FDA-cleared second EIA
    Recommended strategyPerform a sensitive EIA or IFA first; if reactive or equivocal, perform a confirmatory Western immunoblot or FDA-cleared second EIA
    Intended useUsed for serologic diagnosis of symptomatic individuals with travel to a Lyme-endemic region and specified clinical presentations

    Background

    Serologic testing for Lyme disease typically follows a two‑tier strategy: an initial sensitive screening assay (enzyme immunoassay/EIA or immunofluorescence assay/IFA) followed by a confirmatory test (western immunoblot or an FDA‑cleared second EIA). This approach is the recommended method for serologic diagnosis in symptomatic patients with a history of travel to a Lyme‑endemic region. For early neurologic presentations with symptom duration under 14 days, polymerase chain reaction (PCR)–based direct detection of B. burgdorferi in cerebrospinal fluid (CSF) may be used and can replace serology during the seroconversion window.

    Policy Summary
    PayerBlue Cross Blue Shield - New Mexico
    PolicyLyme Disease Testing
    Policy CodePolicy CPCPLAB044
    Change TypeAdded codeclarified reimbursement language
    Effective DateAug 1, 2025
    Last ReviewAug 1, 2025
    Next Review Date
    Key ActionVerify product-level coverage and prior authorization requirements before ordering Lyme testing.
    SourceLink
    On This Page
    Coverage Criteria for Lyme Disease TestingSpecific Covered IndicationsProcedure and Test CodesProvider Actions and Documentation RequirementsNot Covered ServicesFrequency and Repeat TestingDefinitions and Testing StrategiesBackground

    [[chunk 3]]

    Repeat serology after prior positive: Repeat serologic testing for individuals who have previously tested positive for Lyme disease is not reimbursable.

    [[chunk 4]]

    Other/unspecified Borrelia tests: All other testing for Borrelia burgdorferi not described in this policy is not reimbursable.

    [[chunk 4]]

    Tick testing: Testing the removed tick for diagnosis of Lyme disease is not reimbursable.

    [[chunk 4]]

    <14 days symptom duration

    [[chunk 4]]

    Verify product-level coverage and prior authorization requirements before ordering. Not all lab management reimbursement criteria apply to every product; coverage determinations are made at the plan level.

    • Contact the member's plan or check benefits to confirm coverage and any prior authorization requirement.
    • Order testing only for medically appropriate patients meeting the clinical indications described in the policy.
    Denial Risk

    Denial triggers for non-covered indications

    Do not order or expect reimbursement for serologic testing for Lyme disease in non-covered indications. Common denial triggers include testing for screening of asymptomatic individuals, testing for erythema migrans when the rash is present (treat empirically instead), testing for non‑specific symptoms alone, or repeat serologic testing after a prior positive result without new clinical justification.

    • Not reimbursable: testing for erythema migrans (EM) rash; screen asymptomatic patients living in endemic areas; evaluation of only non‑specific symptoms (fatigue, myalgias/arthralgias).
    • Not reimbursable: testing for neurologic/degenerative and psychiatric conditions listed (ALS, MS relapse-remitting, Parkinson's, dementia/cognitive decline, new-onset seizures, psychiatric illness) when used to support Lyme diagnosis.
    • Not reimbursable: repeat serologic testing after prior positive result, testing of the tick, and any other Borrelia burgdorferi tests not described as reimbursable in the policy.
    Documentation Required

    Ordering requirements

    Ordering requirements: confirm that the patient meets medical criteria for Lyme disease testing before ordering. Use recommended testing methods for the indicated clinical scenario (2‑tier serologic testing for most symptomatic patients with compatible history; PCR on CSF may be appropriate for early neurologic disease <14 days).

    • Order 2‑tier serologic testing (sensitive EIA/IFA followed by Western blot or FDA‑cleared second EIA) for symptomatic individuals with compatible exposure or travel history.
    • Consider PCR on CSF for patients with short-duration neurologic symptoms (<14 days) where antibody production may not yet be detectable.
    • Do not order testing for the tick; do not repeat serologic testing without new clinical justification.