CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB044

Lyme Disease - Laboratory Testing Reimbursement

Defines BCBS Oklahoma reimbursement criteria for laboratory testing for Lyme disease, including which serologic, PCR, and other tests are reimbursable or not, and applies to providers submitting claims to BCBS OK.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyLyme Disease - Laboratory Testing Reimbursement

Policy CodePolicy CPCPLAB044

Change TypeNo material changes

Effective DateNov 1, 2022

Next Review Date

Key ActionSubmit claims with accurate documentation using HIPAA-approved code sets; ensure serologic 2-tier testing or CSF PCR meet clinical criteria for reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2-tier serologyPreferred reimbursable strategy

PCR <14 daysCSF PCR allowance

8 categoriesNon-reimbursable categories

DiscouragedRepeat testing

Not reimbursableTick testing

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Reimbursement Criteria for Lyme Disease Testing

Reimbursement criteria for Lyme disease testing

Covered when the following clinical criteria and exclusions are met:

ALL of the following

Eligible clinical presentations
- Patients with a history of travel to a Lyme region (with or without a history of a tick bite) with compatible symptoms of Lyme disease
- Patients with a history of travel to a Lyme region presenting with acute myocarditis or pericarditis of unknown cause
- Patients with a history of travel to a Lyme region presenting with meningitis, encephalitis, or myelitis
- Patients with a history of travel to a Lyme region presenting with painful radiculoneuritis
- Patients with a history of travel to a Lyme region presenting with mononeuropathy multiplex (including confluent mononeuropathy multiplex)
- Patients with a history of travel to a Lyme region presenting with acute cranial neuropathy
Testing method: two-tier strategy using a sensitive EIA or immunofluorescence assay followed by a western immunoblot assay or FDA-cleared second EIA assay

ALL of the following

Not reimbursable in
- Patients with an erythema migrans (EM) rash; patients with skin rashes consistent with EM who reside in or have recently traveled to an endemic area should be treated for Lyme disease (do not use serology)
- Screening of asymptomatic patients living in endemic areas
- Patients with only non-specific symptoms (e.g., fatigue, myalgias/arthralgias)
- Patients with amyotrophic lateral sclerosis (ALS)
- Patients with relapsing-remitting multiple sclerosis

ALL of the following

PCR of CSF may be reimbursable and may replace serologic documentation in patients with neurologic symptoms of short duration (<14 days) during the window before detectable antibody production

ALL of the following

Repeat serologic testing is not reimbursable in individuals who previously tested positive since positive results may not distinguish between past and current infection(s)
Repeat PCR-based detection of B. burgdorferi is not reimbursable to justify continuation of IV antibiotics beyond one month in patients with persistent symptoms
Repeat PCR-based detection is not reimbursable as a technique to follow therapeutic response
Repeat PCR-based detection is not reimbursable via urine sample

ALL of the following

Genotyping and phenotyping tests for Borrelia burgdorferi are not reimbursable
Determination of CXCL13 levels is not reimbursable
Urine assays, including urinary-based antigen capture assays, are not reimbursable
Panel immunoblot testing (for example Lyme ImmunoBlot IgM, Lyme ImmunoBlot IgG, Lyme Dot Blot) is not reimbursable
Testing of the individual tick is not reimbursable for diagnosis of Lyme disease

ALL of the following

Serologic testing described above refers to a two-tier testing strategy (sensitive EIA or immunofluorescence followed by western immunoblot or FDA-cleared second EIA)

Coding and Clinical Thresholds

Coding and billing guidancemixed

Use HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC) and follow industry coding guidelines; specific Lyme test codes not listed in this policy.

Clinical pre-test probability threshold

Clinical presentation requirementSerologic testing reimbursable only for patients with compatible symptoms of Lyme disease (see specific neurologic, cardiac, and neuropathic presentations).

Travel/residence history requirementHistory of travel to a Lyme region (with or without a history of a tick bite) is required for serologic testing to be reimbursable.

Specific clinical syndromes qualifyingReimbursable for acute myocarditis/pericarditis, meningitis/encephalitis/myelitis, painful radiculoneuritis, mononeuropathy multiplex (including confluent), or acute cranial neuropathy when travel history and compatible symptoms are present.

Not reimbursable — EM rashSerologic testing is not reimbursable for patients with erythema migrans (EM) rash; such patients in or recently returned from endemic areas should be treated without serology.

Not reimbursable — screening and non-specific symptomsNot reimbursable for asymptomatic screening in endemic areas or for patients with only non-specific symptoms (e.g., fatigue, myalgias/arthralgias) due to low pre-test probability and false positives.

Not reimbursable — specific neurologic/degenerative/psychiatric conditionsNot reimbursable for patients with ALS, relapsing‑remitting MS, Parkinson's disease, dementia/cognitive decline or new‑onset seizures, or psychiatric illness.

Claim Submission and Prior Authorization

Documentation Required

Claim submission and documentation requirements

Providers are responsible for submitting accurate documentation and using valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, etc.). Claims are subject to code edits and review against benefit terms, provider contract language, medical and clinical payment and coding policies. Upon request, submit additional supporting documentation.

Use industry-standard coding guidelines (AMA CPT, UB, CMS NCCI, CCI edits).
Claims may be reviewed for medical necessity and contract/plan coverage; documentation must show clinical rationale.

Prior Authorization

Prior Authorization / Coverage Conditions (Clinical Criteria)

Prior authorization / coverage conditions: 2-tier serologic testing (sensitive EIA or immunofluorescence assay followed by Western blot or FDA-cleared second EIA) may be reimbursable for patients with compatible symptoms and travel to a Lyme region, and for patients with specific neurologic or cardiac presentations. CSF PCR for B. burgdorferi may be reimbursable for patients with short-duration neurologic symptoms (<14 days) and can replace serology during the pre-seroconversion window. Certain uses and repeat testing are not reimbursable.

Covered when ALL of the following: travel to a Lyme-endemic region (or residence) AND compatible clinical presentation (may include erythema migrans exception noted below).
2-tier serology may be reimbursed for patients with: acute myocarditis/pericarditis of unknown cause; meningitis, encephalitis, or myelitis; painful radiculoneuritis; mononeuropathy multiplex (including confluent); acute cranial neuropathy.
CSF PCR may be reimbursed for direct detection in patients with neurologic symptoms <14 days (may replace serology).
Not reimbursable: serology for patients with erythema migrans (treat clinically), screening asymptomatic persons, patients with only non-specific symptoms (fatigue, myalgias/arthralgias), patients with ALS, relapsing-remitting MS, Parkinson's, dementia/cognitive decline or new seizures, psychiatric illness.
Repeat testing limits: repeat serologic testing after a prior positive is not reimbursable; repeat PCR is not reimbursable to justify prolonged IV antibiotics beyond one month, to monitor therapeutic response, or when performed on urine samples.
Other tests (e.g., genotyping/phenotyping) are not reimbursable.

Key Test Definitions

2-tier testing — definition

DefinitionTwo-tier serologic testing: an initial sensitive EIA or immunofluorescence assay followed by a western immunoblot assay or an FDA‑cleared second EIA.

PurposeImproves specificity by confirming positive or equivocal initial EIA/IFA results with a second, more specific assay.

Reimbursement contextBCBSOK describes the 2-tier strategy as the preferred serologic testing approach for reimbursable Lyme disease testing when clinical criteria are met.

PCR (CSF) — definition and context where used

DefinitionPCR-based direct detection of Borrelia burgdorferi in cerebrospinal fluid (CSF).

Clinical contextMay be reimbursable and may replace serologic testing in patients with neurologic symptoms of short duration (<14 days) during the window before antibody production.

Limitations on repeat useRepeat PCR-based detection is not reimbursable to justify prolonged IV antibiotics beyond one month, to follow therapeutic response, or when performed on urine samples.