CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB044

Lyme Disease Testing

Defines Blue Cross Blue Shield - Oklahoma reimbursement criteria for laboratory testing for Lyme disease (serologic and PCR) including when two-tier serology or PCR of CSF is reimbursable and situations where testing is not reimbursable. Applies to providers submitting claims to BCBSOK.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyLyme Disease Testing

Policy CodePolicy CPCPLAB044

Change TypeRevised (2023-08-15)

Effective DateNov 1, 2023

Next Review Date

Key ActionDocument travel/exposure to an endemic area and specific clinical signs/symptoms when ordering two-tier serologic testing; be prepared to supply supporting documentation on claim review.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information revised for clarity and literature review added on 2023-08-15.

1Policy covering Lyme disease testing (CPCPLAB044)

7Listed procedure codes related to Lyme testing

8Situations explicitly listed where serologic testing is not reimbursable

Reimbursable and Non-Reimbursable Lyme Disease Testing

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Reimbursable serologic testing (two-tier) for specific clinical presentations without explicit mention of 'symptoms of Lyme disease'

For individuals with a history of travel to an endemic region, two-tier serologic testing may be reimbursable for any of the following presentations:

ONE of the following

Acute myocarditis or pericarditis of unknown cause
Meningitis, encephalitis, or myelitis
Painful radiculoneuritis
Mononeuropathy multiplex (including confluent mononeuropathy multiplex)
Acute cranial neuropathy

Not reimbursable - serologic testing

Serologic testing is not reimbursable in any of the following situations:

ANY of the following

Erythema migrans (EM) rash — patients with EM should be treated for Lyme disease without serologic testing
Screening of asymptomatic patients living in endemic areas
Individuals with non-specific symptoms only (e.g., fatigue, myalgias/arthralgias)
Individuals with amyotrophic lateral sclerosis (ALS)
Individuals with relapsing-remitting multiple sclerosis
Individuals with Parkinson's disease
Individuals with dementia or cognitive decline, or new-onset seizures
Individuals with psychiatric illness

Reimbursable - PCR-based direct detection in CSF

PCR of CSF for B. burgdorferi may be reimbursable under a specific timing/clinical circumstance:

ALL of the following

PCR-based direct detection of B. burgdorferi performed on CSF samples
Patient has neurologic symptoms of short duration (< 14 days) — testing may replace serologic documentation during window before detectable antibodies

Procedure and Proprietary Test Codes Referenced

Procedure / test codes referencedmixed

86617	Antibody; Borrelia burgdorferi (Lyme disease), IgG
86618	Antibody; Borrelia burgdorferi (Lyme disease), IgM
87475	Infectious agent detection by nucleic acid (eg, PCR), Borrelia burgdorferi
87476	Infectious agent detection by nucleic acid (eg, PCR), Borrelia spp. (specify)
0041U	Laboratory test, Lyme disease, clear description (proprietary code)
0042U	Laboratory test, Lyme disease, clear description (proprietary code)
0316U	Laboratory test, Lyme disease, modified two-tier testing (MTTT) or other proprietary assay

Documentation and Denial Risk Guidance for Providers

Documentation Required

Document travel/exposure and clinical presentation

When ordering two‑tier serologic testing for Lyme disease, document the patient’s history of travel to or residence in an endemic area (or known exposure) and the specific clinical signs or symptoms consistent with Lyme disease. Claim review may request additional supporting documentation.

86617
86618
0041U
0042U
0316U

Denial Risk

Testing likely denied if not meeting listed indications

Claims for serologic or other Borrelia testing may be denied when performed for indications explicitly listed as not reimbursable, including screening, non‑specific symptoms alone, testing patients with an EM rash, repeat serology after a prior positive, testing of ticks, or assays not described in this policy.

86617
86618
0041U
0042U
0316U
87475
87476

Clinical and Testing Context

The policy identifies specific non‑reimbursable situations. Testing of the tick itself for diagnosis is not reimbursable, and serologic testing is not reimbursable for individuals with an erythema migrans (EM) rash (these patients should be treated without serologic testing), for routine screening of asymptomatic persons in endemic areas, for repeat serologic testing after a prior positive, or for evaluation of non‑specific symptoms alone or certain neurologic, psychiatric, or neurodegenerative conditions listed in the policy. Procedure codes commonly associated with Lyme testing are listed in the policy and may be denied when used in these non‑covered circumstances.