CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Rhode Island-mandated coverage for certain Lyme disease treatments

Defines BCBSRI coverage requirements for diagnostic testing and long-term antibiotic treatment of chronic Lyme disease per Rhode Island General Law §27-20-48, and describes applicability to Medicare Advantage and commercial products and related lab/authorization restrictions.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyRhode Island-mandated coverage for certain Lyme disease treatments

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 6, 2024

Next Review DateApr 1, 2026

Key ActionServices must be ordered by the treating physician after evaluation of symptoms, diagnostic test results, and response to treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

§27-20-48State law mandating coverage

13 codesTesting codes listed

Ordering physician onlyAuthorization participation

Medicare & CommercialApplies to

Coverage Criteria

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Rhode Island-mandated coverage criteria

Covered when ALL of the following are met:

State-mandated coverage conditions: Services are 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.

Per RIGL §27-20-48, treatment otherwise eligible shall not be denied solely because it may be characterized as unproven, experimental, or investigational.

Some genetic testing services may be not covered or subject to a contract exclusion for self‑funded groups that have excluded the expanded coverage of biomarker testing related to the state mandate (R.I.G.L. §27‑1981). For details on which genetic tests require prior authorization, are considered not medically necessary, or are excluded, refer to the Coding section of the Genetic Testing Services or Proprietary Laboratory Analyses (PLA) policies and the member's Benefit Booklet.

Not applicable. The policy specifies "Not applicable" under MEDICAL CRITERIA, indicating there are no separate internal medical‑necessity criteria beyond the requirements set by Rhode Island law (R.I.G.L. §27‑20‑48).

Coding

Lyme disease and related testing 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 protein groups, by immunoblot, IgG.
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	Infectious agent detection by nucleic acid (DNA or RNA), Bartonella henselae and Bartonella quintana, ddPCR; following liquid enhancement.
0316U	Borrelia burgdorferi (Lyme disease), OspA protein evaluation, urine.

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Provider Actions and Billing Rules

Prior Authorization

Prior Authorization Not Applicable

Prior authorization is not applicable for these services. The ordering physician must evaluate the patient and order services; laboratories may not obtain prior authorization on behalf of the ordering physician.

Prior authorization: Not applicable
Ordering requirement: Services must be ordered by the physician or qualified clinician after evaluation

Note

Ordering and Authorization Responsibility

Only the ordering physician (or other qualified healthcare professional) may be involved in authorization, appeals, or related administrative processes. Laboratories and laboratory representatives are prohibited from obtaining authorizations, facilitating the authorization process, or participating in appeals on behalf of the ordering physician.

Laboratories are not allowed to obtain clinical authorization or participate in the authorization process on behalf of the ordering physician
Use of a laboratory representative or third party to obtain authorization or assist in appeals is a violation and may lead to termination from BCBSRI network

Denial Risk

Unauthorized Laboratory Services Denied

If a laboratory provides a service that has not been authorized, the service will be denied and the financial liability will fall on the provider (laboratory). Such unauthorized lab services may not be billed to the member.

Unauthorized lab services are denied as the financial liability of the provider
Do not bill members for unauthorized lab services

Billing Rule

Lyme Disease Testing and Treatment — Ordering Requirement

For Medicare Advantage and Commercial products, and per Rhode Island law, diagnostic testing and long-term antibiotic treatment for chronic Lyme disease are covered when ordered by a physician or other qualified healthcare professional after evaluation of symptoms, test results, and treatment response. Coverage cannot be denied solely because treatment is characterized as unproven, experimental, or investigational.

Applies to Medicare Advantage Plans and Commercial Products
Ordering requirement: Physician or qualified healthcare professional must evaluate and order

Definitions

Diagnostic testing and long-term antibiotic treatment when determined medically necessary and ordered by a physician per RIGL §27-20-48

Statutory basisRhode Island General Law §27-20-48 requires coverage for diagnostic testing and long-term antibiotic treatment of chronic Lyme disease when medically necessary and ordered by a physician.

Coverage condition (most actionable)Covered when services are ordered by a physician after a thorough evaluation of the patient's symptoms, diagnostic test results, and response to treatment and determined to be medically necessary per RIGL §27-20-48.

Ordering requirementServices must be ordered by a physician acting in accordance with chapter 37.5 of title 5 (Lyme disease diagnosis and treatment).

Treatment determinationTreatment shall not be denied solely because it may be characterized as unproven, experimental, or investigational in nature.

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

Background

Lyme disease is caused primarily by Borrelia burgdorferi and is transmitted by blacklegged (deer) ticks. Clinical presentation can include fever, headache, fatigue, and the characteristic erythema migrans rash; if untreated, infection may progress to involve joints, the heart, and the nervous system. Most cases respond to a standard course of antibiotics, but Rhode Island law (R.I.G.L. §27‑20‑48) requires coverage for diagnostic testing and long‑term antibiotic treatment of chronic Lyme disease when those services are determined to be medically necessary and ordered by a physician.