CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Lyme Disease Diagnosis and Treatment Mandate (RIGL 27-20-48)

State-mandated coverage requirements (Rhode Island RIGL 27-20-48) for diagnostic testing and long-term antibiotic treatment of chronic Lyme disease for members of Blue Cross & Blue Shield of Rhode Island products; describes applicability and product variations.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyLyme Disease Diagnosis and Treatment Mandate (RIGL 27-20-48)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateSep 20, 2024

Key ActionOrder services only after a physician or qualified healthcare professional evaluates symptoms, diagnostic test results, and response to treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

RIGL 27-20-48governing statute

9 codescovered test codes

Mostproducts

Coverage Criteria for Lyme Disease Testing and Treatment

Coverage for diagnostic testing and long-term antibiotic treatment

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Coverage for genetic and biomarker testing under this policy may vary by product. Some genetic services may not be covered for self‑funded groups per the state’s Biomarker Testing Mandate and Blue Cross & Blue Shield of Rhode Island’s Genetic Services and Proprietary Laboratory Analyses policies. Members and providers should consult the member’s benefit booklet / Evidence of Coverage or Subscriber Agreement to determine whether a specific genetic or biomarker test is covered, requires authorization, is considered not medically necessary, or is a contract exclusion.

Coding — Test and Laboratory Codes

Testing codes listedmixedCovered

86617	Antibody; Borrelia burgdorferi (Lyme disease) confirmatory test (eg, Western Blot or immunoblot).
86618	Antibody; Borrelia burgdorferi (Lyme disease).
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, droplet digital PCR (ddPCR); following liquid enhancement.
0316U	Borrelia burgdorferi (Lyme disease), OspA protein evaluation, urine.

Provider Actions, Authorization & Documentation

Prior Authorization

Prior authorization is not applicable.

Step Therapy

Medical criteria / Step therapy

Not applicable.

Documentation Required

Required clinical documentation

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. Benefit payment for Lyme disease diagnostic testing and long-term antibiotic treatment will not be denied solely because such treatment may be characterized as unproven, experimental, or investigational.

Applies to Medicare Advantage Plans and Commercial Products per Rhode Island General Law 27-20-48.
Orders must follow chapter 37.5 of title 5 regarding Lyme disease diagnosis and treatment.

Denial Risk

Ordering and denial protection

Benefit payment will not be denied solely because treatment may be characterized as unproven, experimental, or investigational. Coverage provided in accordance with Rhode Island General Law 27-20-48 requires that diagnostic testing and long-term antibiotic treatment for chronic Lyme disease be determined medically necessary and ordered by a physician after evaluation.

Background

Lyme disease is an infection caused primarily by the spirochete Borrelia burgdorferi (and, rarely, Borrelia mayonii) transmitted by blacklegged ticks. Common clinical features include fever, headache, fatigue, and erythema migrans. If untreated, infection can disseminate to involve the joints, cardia, and nervous system. Diagnosis is based on the patient’s symptoms, physical findings, history of possible tick exposure, and appropriate validated laboratory testing.

Definitions

Definition of Chronic Lyme disease (RIGL 27-20-48)

Definition (term)Chronic Lyme disease

Statutory referenceAs referenced in RIGL 27-20-48

Ordering requirementMust be ordered by a physician in accordance with chapter 37.5 of title 5 following evaluation of symptoms, test results, and treatment response.

Denial protectionTreatment eligible under this provision shall not be denied solely because it may be characterized as unproven, experimental, or investigational.