CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB044

Lyme Disease Testing

Defines BCBSNM reimbursement criteria for laboratory testing to diagnose Lyme disease, including when serologic two-tier testing, PCR of CSF, repeat testing, and tick testing are reimbursable or not; applies to providers submitting claims to Blue Cross Blue Shield of New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyLyme Disease Testing

Policy CodePolicy CPCPLAB044

Change TypeRevised (8/15/2023)

Effective DateAug 15, 2023

Next Review DateN/A

Key ActionProviders must submit accurate documentation and code claims using HIPAA-approved code sets; claims are subject to review against plan documents, provider contracts, clinical payment and coding policies, and coding edit protocols.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information revised for clarity following a literature review.

7procedure codes listed

6non-reimbursable scenarios

5reimbursable situations

1policy version

Lyme Testing Reimbursement Criteria

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyLyme Disease Testing

Policy CodePolicy CPCPLAB044

Change TypeRevised (8/15/2023)

Effective DateAug 15, 2023

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ANY of the following

Symptomatic with endemic travel: Serologic testing using a two-tier strategy (sensitive EIA or immunofluorescence assay 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 known tick bite).
Neurologic/cardiac/neuropathy indications: For individuals with a history of travel to a Lyme-endemic region, serologic two-tier testing may be reimbursable for any of the following presentations: (a) acute myocarditis or pericarditis of unknown cause; (b) meningitis, encephalitis, or myelitis; (c) painful radiculoneuritis; (d) mononeuropathy multiplex (including confluent mononeuropathy multiplex); or (e) acute cranial neuropathy.

PCR of CSF for early neurologic disease: PCR-based direct detection of B. burgdorferi in cerebrospinal fluid may be reimbursable and may replace serologic testing for patients with neurologic symptoms of short duration (<14 days) during the window before detectable antibodies are produced.

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

Non-reimbursable clinical scenarios: Serologic testing is not reimbursable for: (a) individuals with an erythema migrans rash (these patients should be treated clinically); (b) screening asymptomatic patients in endemic areas; (c) individuals with only non-specific symptoms (e.g., fatigue, myalgias/arthralgias); (d) individuals with amyotrophic lateral sclerosis; (e) individuals with relapsing-remitting multiple sclerosis; (f) individuals with Parkinson’s disease; (g) individuals with dementia or cognitive decline or new-onset seizures; or (h) individuals with psychiatric illness.

Other tests and tick testing: All other testing for Borrelia burgdorferi not described above is not reimbursable. Testing of the tick for diagnosis of Lyme disease is not reimbursable.

Plan variability note

Coding caveat

Documentation and Claims Review

Documentation Required

Documentation, coding, and claims review requirements

Providers must submit accurate documentation of services performed and submit claims using valid code combinations from HIPAA‑approved code sets. Claims are subject to code edit protocols and review against benefit coverage, provider contracts, medical policies, clinical payment and coding policies, and coding software logic; providers may be asked to submit additional documentation upon request.

Use HIPAA‑approved code sets and industry-standard coding guidelines (CPT, HCPCS, ICD-10, NDC, DRG, CMS NCCI/CCI edits, UB, AMA resources).
Claims are subject to code edit protocols and claim review and may require submission of additional documentation.
Plan documents or provider contracts govern if they conflict with this policy.

Key Testing Definitions

inv-04: Two-tier testing — two-tier serologic testing

DefinitionTwo-tier serologic testing: an initial sensitive enzyme immunoassay (EIA) or immunofluorescence assay followed by a Western immunoblot assay or an FDA-cleared second EIA assay.

When reimbursableMay be reimbursable for individuals with symptoms of Lyme disease and history of travel to a Lyme-endemic region (with or without known tick bite).

Additional reimbursable indicationsMay be reimbursable for individuals from endemic regions presenting with acute myocarditis/pericarditis, meningitis/encephalitis/myelitis, painful radiculoneuritis, mononeuropathy multiplex, or acute cranial neuropathy.

Not reimbursable — erythema migransNot reimbursable for individuals with an erythema migrans (EM) rash; such patients in endemic areas should be treated clinically.

Not reimbursable — screening & nonspecific symptomsNot reimbursable for screening asymptomatic patients in endemic areas or for individuals with only non-specific symptoms (e.g., fatigue, myalgias/arthralgias).

inv-05: PCR of CSF — polymerase chain reaction-based direct detection of B. burgdorferi in CSF

DefinitionPolymerase chain reaction (PCR)-based direct detection of B. burgdorferi in cerebrospinal fluid (CSF).

Reimbursable useMay be reimbursable and may replace serologic documentation in patients with neurologic symptoms of short duration (<14 days) during the window before detectable antibodies develop.

Clinical contextIntended for patients with recent onset neurologic manifestations where serology may be negative due to early presentation (<14 days).

Related limitationPolicy specifies use in CSF samples; other direct detection tests or sample types not described are considered not reimbursable unless specified elsewhere in the policy.

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OpenPayer

Lyme Disease Testing

Lyme Testing Reimbursement Criteria

Procedure Codes Referenced

Documentation and Claims Review

Key Testing Definitions