CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB044

Lyme Disease Testing

Defines reimbursement and coverage criteria for laboratory testing for Borrelia burgdorferi (Lyme disease) for Blue Cross Blue Shield - Oklahoma members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyLyme Disease Testing

Policy CodePolicy CPCPLAB044

Change TypeLiterature reviewreferences revised

Effective DateJan 15, 2025

Next Review Date

Key ActionVerify product-specific coverage and prior authorization requirements in plan documents before ordering Lyme testing.

SourceLink

POLICY UPDATE CHANGES

Document updated with literature review; reimbursement information unchanged; references revised.

7Procedure codes listed

3Reimbursable situations

8Non-reimbursable indications

14 daysPCR window

CPCPLAB044Policy id

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Covered testing indications

Serologic testing and PCR for Lyme disease are covered only in specified clinical scenarios:

Serologic testing reimbursable for symptomatic individuals with travel to endemic area: Serologic testing using a two-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 region endemic for Lyme (with or without a history of a tick bite).

Supported by chunk 3

Serologic testing reimbursable for specific clinical presentations: For individuals with a history of travel to a region endemic for Lyme, serologic testing may be reimbursable for any of the following: acute myocarditis or pericarditis of unknown cause; meningitis, encephalitis, or myelitis; painful radiculoneuritis; mononeuropathy multiplex (including confluent mononeuropathy multiplex); or acute cranial neuropathy.

Enumerated list in chunk 3

PCR reimbursable for early neurologic disease: PCR-based direct detection of B. burgdorferi in CSF may be reimbursable and may replace serologic documentation of infection in patients with a short duration of neurologic symptoms (less than 14 days).<14 days

Chunk 4

Serologic testing for Lyme disease is not reimbursable in several specific clinical contexts. These include testing when a patient has an erythema migrans (EM) rash (such patients residing in or recently traveling to an endemic area should be treated clinically rather than tested), asymptomatic screening of individuals who live in endemic areas, and evaluation of patients with non‑specific symptoms only (for example, fatigue, myalgias, or arthralgias). The policy also enumerates certain neurologic and neurodegenerative diagnoses and psychiatric illness as non‑reimbursable indications for serology (including amyotrophic lateral sclerosis, relapsing‑remitting multiple sclerosis, Parkinson’s disease, dementia/cognitive decline, and new‑onset seizures).

Repeat serologic testing after an individual has previously tested positive for Lyme disease is explicitly not reimbursable under this policy. Providers should therefore not expect coverage for serial or confirmatory antibody testing in members with a documented prior positive result.

Specific Covered Indications

Symptomatic individuals with travel to an endemic region; specific neurologic and cardiac presentations

Covered when the member is symptomatic and has epidemiologic risk or presents with specific neurologic or cardiac findings:

Symptomatic with travel to endemic region: Individual has symptoms consistent with Lyme disease and a history of travel to a Lyme-endemic region (with or without a known tick bite); two-tier serologic testing may be reimbursable.

Chunk 3

Specific neurologic presentations: For individuals with travel to an endemic region, serologic testing may be reimbursable for any of the following neurologic manifestations: meningitis, encephalitis, myelitis, painful radiculoneuritis, mononeuropathy multiplex (including confluent), or acute cranial neuropathy.

Chunk 3

Specific cardiac presentation: For individuals with travel to an endemic region, serologic testing may be reimbursable for acute myocarditis or pericarditis of unknown cause.

Chunk 3

PCR option for early neurologic symptoms: PCR-based direct detection of B. burgdorferi in CSF may be used and reimbursable in place of serology for patients with a short duration of neurologic symptoms (less than 14 days) during the window before detectable antibodies develop.<14 days

Chunk 4

Provider Responsibilities and Operational Notes

Prior Authorization

Verify product-specific authorization

Not all requirements apply to every product. Verify member coverage and any product-specific prior authorization or lab management rules in plan documents before ordering testing.

Providers should review the member's benefit documents for coverage and prior authorization requirements.
BCBSOK may apply product-specific lab management reimbursement criteria.

Note

Testing sequence recommendation

Two-tier serologic testing is the recommended sequence when serology is appropriate: begin with a sensitive enzyme immunoassay (EIA) or immunofluorescence assay (IFA), and if positive or equivocal, perform a confirmatory Western immunoblot OR an FDA-cleared second EIA assay.

Initial test: sensitive EIA or IFA.
Confirmatory test: Western blot OR FDA-cleared second EIA (per two-tier testing strategy).
Reimburseable when clinical criteria met (see reimbursement criteria).

Documentation Required

Claims and documentation expectations

Providers are responsible for accurate documentation and proper claim submission using valid HIPAA code sets. Claims are subject to coding edits, review against benefit documents, provider contracts, and applicable policies; additional documentation may be requested.

Submit claims using industry-standard code sets (CPT, HCPCS, ICD-10, NDC, etc.).
Expect claim review and code-edit protocols; provide supporting documentation upon request.

Denial Risk

Non-reimbursable serologic testing triggers

Serologic testing is not reimbursable in certain clinical contexts; do not order serology for these presentations.

Not reimbursable for individuals with an erythema migrans (EM) rash — treat clinically in endemic areas.
Not reimbursable for asymptomatic screening of patients living in endemic areas.
Not reimbursable for individuals presenting with only non-specific symptoms (e.g., fatigue, myalgias, arthralgias).

Denial Risk

Other non-reimbursable situations

Additional non-reimbursable situations include repeat positive serologic testing, testing the tick, and other tests not described as reimbursable by BCBSOK.

Repeat serologic testing for individuals who previously tested positive is not reimbursable.
Testing the tick for Borrelia burgdorferi is not reimbursable.
All other testing for B. burgdorferi not specifically described as reimbursable is not covered.

Ordering and Authorization Requirements

Billing Rule

Ordering requirements and documentation submission

Verify member plan documents for product-specific coverage and any required prior authorization before ordering; submit claims with accurate documentation and valid HIPAA code sets for Lyme disease testing.

Confirm whether the member’s plan requires prior authorization for codes listed in this policy (86617, 86618, 87475, 87476, 0041U, 0042U, 0316U).
Ensure claims use valid HIPAA-approved code combinations and be prepared to supply supporting documentation if requested.

Not Covered Services

The following are stated as not covered: testing of the tick for Borrelia burgdorferi; serologic testing when an erythema migrans (EM) rash is present (manage clinically); asymptomatic screening of individuals in endemic areas; serologic testing performed solely for non‑specific symptoms (e.g., fatigue, myalgias/arthralgias); and repeat serologic testing for individuals with a prior positive test. The policy also indicates that other Borrelia testing not specifically described in the document is not reimbursable.

Key Definitions

Two-tier testing strategy using EIA/IFA followed by Western blot or FDA-cleared second EIA

Preferred sequenceTwo‑tier serologic testing: a sensitive EIA or IFA first, followed by a Western immunoblot or an FDA‑cleared second EIA.

Indications when reimbursableSymptomatic individuals with travel to an endemic region; specific presentations include acute myocarditis/pericarditis, meningitis/encephalitis/myelitis, painful radiculoneuritis, mononeuropathy multiplex, and acute cranial neuropathy.

Test typesEnzyme immunoassay (EIA), immunofluorescence assay (IFA), Western immunoblot, FDA‑cleared second EIA.

NotesIn reimbursable situations, use the two‑tier approach as described for serologic diagnosis of Lyme disease.

Polymerase chain reaction (PCR)-based direct detection of B. burgdorferi in CSF

Policy statementPCR-based direct detection of B. burgdorferi in CSF may be reimbursable and may replace serology for patients with short-duration neurologic symptoms (<14 days).

Applicable sampleCerebrospinal fluid (CSF).

Clinical contextIntended for use during the window between exposure and production of detectable antibodies (early neurologic disease).

Timing thresholdShort-duration neurologic symptoms defined as less than 14 days from onset.

Background

Diagnosis of Lyme disease relies primarily on clinical assessment supported by laboratory methods. When serologic testing is indicated, the policy describes a two‑tier serologic strategy—an initial sensitive enzyme immunoassay (EIA) or immunofluorescence assay (IFA) followed by a confirmatory Western immunoblot or an FDA‑cleared second EIA. For early neurologic presentations within the first <14 days after symptom onset, PCR‑based direct detection of B. burgdorferi in cerebrospinal fluid (CSF) may be reimbursable and can replace serology during the antibody window period.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyLyme Disease Testing

Policy CodePolicy CPCPLAB044

Change TypeLiterature reviewreferences revised

Effective DateJan 15, 2025

Next Review Date

Key ActionVerify product-specific coverage and prior authorization requirements in plan documents before ordering Lyme testing.

SourceLink

On This Page

OpenPayer

Lyme Disease Testing

Coverage Criteria for Lyme Disease Testing

Specific Covered Indications

Provider Responsibilities and Operational Notes

Procedure Codes

Ordering and Authorization Requirements

Not Covered Services

Frequency and Repeat Testing Limits

Key Definitions

Background

86617	Antibody; Borrelia burgdorferi
86618	Antibody; Borrelia burgdorferi, each
87475	Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi
87476	Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, quantification
0041U	Proprietary or specific Lyme-related assay (listed in policy)
0042U	Proprietary or specific Lyme-related assay (listed in policy)
0316U	Proprietary or specific Lyme-related assay (listed in policy)