CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Rhode Island–mandated coverage for diagnostic testing and long‑term antibiotic treatment of chronic Lyme disease

Defines 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 and notes variability for self‑funded groups.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyRhode Island–mandated coverage for diagnostic testing and long‑term antibiotic treatment of chronic Lyme disease

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateJun 1, 2025

Next Review DateJan 1, 2025

Key ActionOrder services only after physician evaluation confirming medical necessity and document symptoms, diagnostic results, and treatment response.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

RIGL 27-20-48Governing statute

Medicare & CommercialPlan types

Not applicablePrior auth

Not applicableMedical criteria

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Benefits for diagnostic testing and treatment of chronic Lyme disease may vary between groups/contracts. Refer to the member’s applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for specific covered benefits and limitations. Self‑funded employer groups may choose not to follow state mandates, so plan-level documents determine whether the Rhode Island statutory provisions are applied to that group.

This policy is provided for informational purposes only and is not a guarantee of payment. Benefits and eligibility are determined by the member’s subscriber agreement, member certificate, or employer agreement, and those documents supersede the provisions of this medical policy. For member‑specific coverage questions, contact the provider call center.

Coding — Test and Procedure Codes

Testing CPT/HCPCS codes mentionedmixedCovered

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 enrichment
0316U	Borrelia burgdorferi (Lyme disease), OspA protein evaluation, urine

Provider Actions, Documentation, and Billing

Prior Authorization

Prior authorization is not applicable for this policy.

Note

Provider Action

Documentation Required

Ordering and Documentation Requirement

Services must be ordered by a physician or other qualified healthcare professional after a thorough evaluation of the patient’s symptoms, diagnostic test results, and response to treatment.

Denial Risk

Denial Protections under RIGL 27-20-48

Benefit payment will not be denied solely because treatment is characterized as unproven, experimental, or investigational, in accordance with RIGL 27-20-48.

RIGL 27-20-48: Mandatory coverage for diagnostic and long-term antibiotic treatment of chronic Lyme disease when medically necessary and ordered by a physician.

Background

Lyme disease is caused primarily by the spirochete Borrelia burgdorferi and is transmitted by infected blacklegged (Ixodes) ticks. Common early manifestations include erythema migrans (the characteristic expanding skin lesion), fever, headache, and fatigue. If untreated, infection can disseminate and affect the joints, heart, and nervous system. Diagnosis is based on clinical presentation and exposure history supported by appropriately validated laboratory testing. Most cases respond to a short course of antibiotics, although Rhode Island law specifically addresses coverage for diagnostic testing and long‑term antibiotic treatment for chronic Lyme disease when such treatment is determined to be medically necessary after a thorough clinical evaluation.

Definitions

Chronic Lyme disease — definition (RIGL 27-20-48)

Statutory referenceRIGL 27-20-48: Mandatory coverage for diagnostic and long-term antibiotic treatment of chronic Lyme disease when determined to be medically necessary and ordered by a physician acting in accordance with chapter 37.5 of title 5 after a thorough evaluation of symptoms, diagnostic test results, and response to treatment.

Scope of required servicesCoverage must include diagnostic testing and long-term antibiotic treatment for chronic Lyme disease when medically necessary.

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

Non-denial protectionTreatment otherwise eligible for benefits shall not be denied solely because it may be characterized as unproven, experimental, or investigational.

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