CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB044

Lyme Disease Testing

Defines Blue Cross Blue Shield of New Mexico reimbursement criteria for laboratory testing for Lyme disease, including when serologic testing, PCR, and other Borrelia testing are reimbursable or not; applies to providers submitting claims to BCBSNM.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyLyme Disease Testing

Policy CodePolicy CPCPLAB044

Change TypeNo material changes

Effective DateApr 29, 2024

Next Review Date

Key ActionSubmit accurate clinical documentation on claims and provide additional documentation upon request to support medical necessity for Lyme testing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2-tierPreferred strategy

CSF PCRPCR exception

Not reimbursableRepeat testing

ExcludedTick testing

MultipleClinical exclusions

1.0Version

Coverage Criteria for Lyme Disease Testing

Coverage criteria for Lyme disease testing

Reimbursement is conditional based on clinical presentation, travel/residence in endemic regions, and test modality.

Reimbursement requires meeting clinical and testing modality criteria as described below.

Reimbursable serologic testing

Individual has symptoms of Lyme disease and a history of travel to a region endemic for Lyme (with or without a history of a tick bite).
Two-tier serologic testing: a sensitive enzyme immunoassay (EIA) or immunofluorescence assay followed by a Western immunoblot assay or an FDA-cleared second EIA.

Additional reimbursable indications (requires history of travel to an endemic region)

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyLyme Disease Testing

Policy CodePolicy CPCPLAB044

Change TypeNo material changes

Effective DateApr 29, 2024

Next Review Date

Key ActionSubmit accurate clinical documentation on claims and provide additional documentation upon request to support medical necessity for Lyme testing.

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.

Not reimbursable

Erythema migrans (EM) rash — patients with skin rashes consistent with EM who reside in or recently traveled to an endemic area should be treated clinically without testing.
Screening of asymptomatic patients living in endemic areas.
Testing for non-specific symptoms only (e.g., fatigue, myalgias/arthralgias).
Amyotrophic lateral sclerosis.
Relapsing-remitting multiple sclerosis.
Parkinson's disease.
Dementia or cognitive decline, or new-onset seizures.
Psychiatric illness.
Repeat serologic testing for individuals who previously tested positive for Lyme disease.
All other testing for Borrelia burgdorferi not described in this policy.
Testing the tick for diagnosis of the individual — not reimbursable.

Procedure Codes and Clinical Indications

Procedure codes guidancemixed

The policy lists procedure codes are not exhaustive; inclusion does not guarantee coverage.

Clinical indication thresholds — reimbursement contingent on specific clinical indications and test type

Primary clinical requirementIndividuals with symptoms of Lyme disease and history of travel to a Lyme-endemic region (with or without a reported tick bite)

Neurologic and other serious presentationsMeningitis, encephalitis, myelitis, painful radiculoneuritis, mononeuropathy multiplex, acute cranial neuropathy

Cardiac indicationAcute myocarditis or pericarditis of unknown cause

Test-modality conditionalityReimbursement depends on test type: two-tier serologic testing or PCR in CSF for specified situations

Timing constraint for PCR in CSFPCR may replace serology for patients with short-duration neurologic symptoms (<14 days)

Documentation and Claims Review

Documentation Required

Documentation and claims review — submit accurate documentation and provide additional information upon request

Providers must submit accurate documentation of services rendered and use valid code combinations from HIPAA‑approved code sets. Claims are subject to code edit protocols and review against plan documents, provider contracts, medical policies, and coding software logic; upon request, providers should supply additional documentation to support the claim.

Submit claims using valid HIPAA-approved code sets and industry-standard coding guidelines (eg, UB, CPT, HCPCS, ICD-10).
Claims may be reviewed for benefit coverage, provider contract terms, medical and coding policies, and automated code edits.
If requested, provide additional documentation to support services billed.

Testing Definitions

Definition of 2-tier testing

DefinitionA sensitive enzyme immunoassay (EIA) or immunofluorescence assay (IFA) followed by a Western immunoblot assay or an FDA-cleared second EIA

Preferred useTwo-tier serologic testing described as the reimbursable serologic strategy for symptomatic individuals with travel to endemic regions

Application contextsRequired for serologic reimbursement in primary and listed additional clinical presentations (see criteria)

Definition of PCR in CSF

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

Replacement for serologyMay replace serologic documentation of infection for patients with short-duration neurologic symptoms (<14 days)

Reimbursement scopeMay be reimbursable when used in CSF for the specified short-duration neurologic presentation window