CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Rhode Island-mandated coverage for diagnostic and long-term antibiotic treatment of chronic Lyme disease

Governs coverage requirements under Rhode Island General Law 27-20-48 for diagnostic testing and long-term antibiotic treatment of chronic Lyme disease for Blue Cross & Blue Shield of Rhode Island members; applies to Medicare Advantage and Commercial products unless a specific self-funded group excludes the mandate.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyRhode Island-mandated coverage for diagnostic and long-term antibiotic treatment of chronic Lyme disease

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2024

Next Review DateJul 2, 2024

Key ActionOrder diagnostic testing or long-term antibiotic treatment only when determined medically necessary and after physician evaluation of symptoms, test results, and treatment response.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

RIGL 27-20-48Statute

Medicare & CommercialPlan types

CPT/HCPCS/PLACodes listed

Group-dependentBenefit variability

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.

Coverage for diagnostic testing and long-term antibiotic treatment for chronic Lyme disease may vary by employer group. Self-funded groups may have contract exclusions and may choose not to follow state mandates; the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement governs benefits for those members.

This policy is provided for informational purposes only and is not a guarantee of payment or a substitute for clinical judgment. Benefits and eligibility are determined by the member's subscriber agreement, member certificate, or employer agreement, which supersede this policy. If services are determined to be not medically necessary (or are medically necessary but are non-covered benefits under the member's plan), the provider may not charge the member unless the member has been informed and has agreed in writing in advance to accept responsibility for payment.

Testing CPT/HCPCS/PLA Codes

Testing CPT/HCPCS/PLA Codesmixed

86617	Antibody; Borrelia burgdorferi (Lyme disease) confirmatory test (eg, Western Blot or immunoblot).
86618	Antibody; Borrelia burgdorferi (Lyme disease).
86619	Antibody; Borrelia (relapsing fever).
0041U	Borrelia burgdorferi, antibody detection of 5 recombinant protein groups, by immunoblot, IgM.
0042U	Borrelia burgdorferi, antibody detection of 12 recombinant groups, by immunoblot; IgG protein.
0043U	Tick-borne relapsing fever Borrelia group, antibody detection to 4 recombinant protein groups, by immunoblot; IgM.
0044U	Tick-borne relapsing fever Borrelia group, antibody detection to 4 recombinant protein groups, by immunoblot, IgG.
0301U	Infectious agent detection by nucleic acid (DNA or RNA), Bartonella henselae and Bartonella quintana, droplet digital PCR (ddPCR).
0302U	Bartonella quintana, droplet digital PCR (ddPCR); following liquid enhancement.
0316U	Borrelia burgdorferi (Lyme disease), OspA protein evaluation, urine.

Provider Requirements, Prior Authorization, and Billing Notes

Note

Medical criteria

Not applicable

Prior Authorization

Prior authorization

Not applicable

Note

Benefit variability reminder

Self-funded groups may or may not choose to follow state mandates. Benefits may vary between groups/contracts — refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable benefits and coverage. Although Rhode Island-mandated benefits generally do not apply to Plan 65, FEHBP, and Medicare Advantage Plans, Blue Cross & Blue Shield of Rhode Island follows this mandate for all products.

Documentation Required

Ordering requirement and payment protection

To qualify for payment, services must be ordered by a physician or other qualified healthcare professional after evaluation of the patient's symptoms, diagnostic test results, and response to treatment. Benefit payment for Lyme disease treatment will not be denied solely because such treatment may be characterized as unproven, experimental, or investigational.

Step Therapy

No medical criteria/step therapy

No medical criteria or step therapy requirements specified in this policy.

Clinical Background

Lyme disease is a tick-borne infection caused primarily by Borrelia burgdorferi (and rarely Borrelia mayonii). Typical clinical features include fever, headache, fatigue, and the characteristic skin lesion erythema migrans; if untreated, infection can spread to joints, the heart, and the nervous system. Diagnosis is based on symptoms, physical findings, exposure history, and validated laboratory testing, and most cases respond to a few weeks of antibiotics. This policy implements Rhode Island General Law RIGL 27-20-48, which addresses coverage for diagnostic testing and long-term antibiotic treatment for chronic Lyme disease when determined medically necessary by a physician after evaluation of symptoms, diagnostic test results, and response to treatment.

Definitions

Chronic Lyme disease — RIGL 27-20-48 definition

Statutory sourceRhode Island General Law (RIGL) 27-20-48 mandates coverage for diagnostic and long-term antibiotic treatment of chronic Lyme disease for applicable policies issued in the state.

Ordering provider requirementTreatment must be ordered by a physician acting in accordance with chapter 37.5 of title 5 after making a thorough evaluation of the patient, including symptoms, diagnostic test results, and response to treatment.

Coverage noteCoverage shall not be denied solely because the treatment may be characterized as unproven, experimental, or investigational in nature.

Applicable plansApplies to individual or group hospital or medical expense insurance policies or service plan contracts delivered, issued for delivery, or renewed in Rhode Island on or after January 1, 2004.