CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB044

Lyme Disease Testing

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Defines Blue Cross Blue Shield Oklahoma reimbursement and clinical criteria for laboratory testing for Lyme disease (serologic and PCR testing) and lists applicable procedure codes and exclusions. Applies to providers submitting claims to BCBSOK products (review plan documents for product-specific rules).

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyLyme Disease Testing

Policy CodePolicy CPCPLAB044

Change TypeCode additions & reference updates

Effective DateApr 1, 2026

Last ReviewFeb 18, 2026

Next Review Date

Key ActionDocument patient symptoms and endemic exposure for serologic claims; for CSF PCR claims, document neurologic symptom duration <14 days.

SourceLink

POLICY UPDATE CHANGES

Added code 0615U effective 04/01/2026.

Added code 0580U effective 10/01/2025.

Reimbursement information revised for clarity in 11/01/2023 and literature review updates in 2024 and 2023.

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CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB044

Lyme Disease Testing

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Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyLyme Disease Testing

Policy CodePolicy CPCPLAB044

Change TypeCode additions & reference updates

Effective DateApr 1, 2026

Last ReviewFeb 18, 2026

Next Review Date

Key ActionDocument patient symptoms and endemic exposure for serologic claims; for CSF PCR claims, document neurologic symptom duration <14 days.

SourceLink

POLICY UPDATE CHANGES

Added code 0615U effective 04/01/2026.

Added code 0580U effective 10/01/2025.

Reimbursement information revised for clarity in 11/01/2023 and literature review updates in 2024 and 2023.

When Lyme Disease Testing Is Reimbursable

Medically Reimbursable Testing — Symptomatic individuals

Serologic testing (two-tier strategy) may be reimbursable when ALL of the following are met:

ALL of the following

Individual has symptoms of Lyme disease
Individual has a history of travel to a region endemic for Lyme (with or without known tick bite)
Testing uses a 2-tier strategy: sensitive EIA or immunofluorescence assay followed by western immunoblot OR an FDA-cleared second EIA assay
Two-tier testing as defined in policy

Medically Reimbursable Testing — Atypical/serious presentations

For individuals with a history of travel to a Lyme-endemic region, serologic testing (two-tier strategy) may be reimbursable in ANY of the following specific clinical situations:

ANY 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

Screening of asymptomatic patients living in endemic areas
Individuals with an erythema migrans (EM) rash (treat without testing)
Individuals with non-specific symptoms only (e.g., fatigue, myalgias, arthralgias)
Individuals with relapsing-remitting multiple sclerosis
Individuals with amyotrophic lateral sclerosis (ALS)

Medically Reimbursable Testing — Direct detection (PCR)

PCR-based direct detection of B. burgdorferi in CSF may be reimbursable when ALL of the following are met:

ALL of the following

Testing is PCR-based direct detection of B. burgdorferi on CSF samples
Patient has a short duration of neurologic symptoms (< 14 days)< 14 days
PCR may replace serologic documentation during the window before antibodies are detectable
PCR used when antibodies are not yet detectable

Not reimbursable — Other

The following are not reimbursable:

ANY of the following

Repeat serologic testing for individuals who previously tested positive for Lyme disease
All other testing for Borrelia burgdorferi not described in this policy
Testing of the tick for diagnosis of Lyme disease

Procedure Codes Listed in Policy

Procedure codes listed in policyCPT|PLA (misc U-codes included)

86617	Lyme disease serology (C6 peptide ELISA; historically single-tier serology code - policy lists as included code)
86618	Lyme disease serology, confirmatory testing (e.g., western blot) or second-tier testing
87475	Infectious agent detection by nucleic acid (e.g., PCR) for Borrelia burgdorferi (note: listed in policy codes)
87476	Infectious agent detection by nucleic acid (additional/similar code listed)
0041U	Proprietary/PLA code included in list (specific test not described in policy text)
0042U	Proprietary/PLA code included in list (specific test not described in policy text)
0316U	Proprietary/PLA code included in list (specific test not described in policy text)
0580U	Proprietary/PLA code added effective 10/01/2025 (listed in policy)
0615U	Proprietary/PLA code added effective 04/01/2026 (listed in policy)

Documentation, Billing Risks, and Actionable Requirements

Documentation Required

Document endemic exposure and clinical presentation

Document the patient’s symptoms consistent with Lyme disease and note travel to or residence in a Lyme-endemic region (a history of a tick bite is optional) when ordering serologic testing for reimbursement consideration.

Documentation Required

Document acute neurologic symptom duration for PCR

When requesting PCR testing on cerebrospinal fluid for B. burgdorferi, document that the patient has a short duration of neurologic symptoms (less than 14 days) to support PCR use in place of serology.

Clinical and Policy Rationale

This policy endorses a two‑tier serologic testing strategy for diagnosis of Lyme disease: an initial sensitive enzyme immunoassay (EIA) or immunofluorescence assay (IFA) followed by a confirmatory Western immunoblot or an FDA‑cleared second EIA assay. Serologic testing using this approach may be reimbursable for individuals with symptoms of Lyme disease and a history of travel to a Lyme‑endemic region (tick bite history is optional) and for specific serious or atypical clinical presentations (for example, acute myocarditis/pericarditis of unknown cause, meningitis/encephalitis/myelitis, painful radiculoneuritis, mononeuropathy multiplex, or acute cranial neuropathy).

For early neurologic disease when antibodies may not yet be detectable, the policy permits PCR‑based direct detection of Borrelia burgdorferi on CSF. PCR on CSF may be reimbursable and used in place of serology when the patient has a short duration of neurologic symptoms (< 14 days), i.e., during the window before production of detectable antibodies.

Reimbursement under this policy is aligned with clinical presentation and exposure risk: testing is intended for symptomatic individuals with endemic exposure or for the specified serious clinical manifestations listed above. The policy explicitly excludes several low‑yield or inappropriate uses from reimbursement, including testing of patients with an erythema migrans (EM) rash (these patients should be treated without serologic testing), screening of asymptomatic patients who live in endemic areas, and repeat serologic testing for individuals who previously tested positive. Additional not‑reimbursable items include testing of ticks and other Borrelia testing not described in the policy.

Procedure codes listed in the policy include traditional serology and PCR CPT codes as well as miscellaneous PLA/U‑codes; note that PLA codes 0580U and 0615U were added to the code list effective 10/01/2025 and 04/01/2026, respectively. Providers should document symptoms consistent with Lyme disease and history of travel or residence in an endemic area to support serologic testing, and must document short duration of neurologic symptoms (< 14 days) to support CSF PCR testing.

Defined Terms

Definitions

Two-tier testingAn initial sensitive enzyme immunoassay (EIA) or immunofluorescence assay (IFA) followed by a confirmatory Western immunoblot assay or an FDA-cleared second EIA assay.

EM (erythema migrans)The characteristic expanding skin rash of early localized Lyme disease; policy states patients with EM should be treated without serologic testing.

Policy Update Changes

2026-02-18Material code additionLatest

Added PLA code 0615U to the policy (listed with plan effective date 04/01/2026).

2025-08-01Material code addition

Added PLA code 0580U to the policy (listed with plan effective date 10/01/2025).

2024-04-29Documentation/literature update