CurrentCentenePolicy N/A

CONCERT INFECTIOUS DISEASE: VECTOR-BORNE AND TROPICAL DISEASES TESTING (lab)

Outpatient clinical coverage criteria for laboratory testing (serologic and molecular/PCR) for Lyme disease (Borrelia burgdorferi) and Zika virus, specifying medically necessary indications and exclusions.

Policy Summary

PayerCentene

PolicyCONCERT INFECTIOUS DISEASE: VECTOR-BORNE AND TROPICAL DISEASES TESTING (lab)

Policy CodePolicy N/A

Change TypeAdministrative wording, coding correction, formatting

Effective Date

Next Review Date

Key ActionProviders must document plausible exposure and the specific clinical indication when ordering Lyme serologic testing; document seropositivity and treatment rationale for Lyme PCR; and document pregnancy/infant linkage and exposure or ultrasound findings for Zika testing.

SourceLink

POLICY UPDATE CHANGES

Reworded policy statements from 'may be considered medically necessary' to 'are considered medically necessary' for Lyme and Zika test sections.

Corrected CPT code descriptions and removed CPT 86353 from CPT table.

Added 'lab' to policy title and moved CPT code table into coding implications section.

2Diseases covered (Lyme, Zika)

4Supported Lyme serologic indications

1Specific PCR scenario for Lyme arthritis

Coverage Summary

Scope: Outpatient clinical coverage criteria for laboratory testing (serologic and molecular/PCR) for Lyme disease (Borrelia burgdorferi) and Zika virus, specifying medically necessary indications and exclusions.

Status: CURRENT policy describing medically necessary and not-supported indications for Lyme and Zika testing in the outpatient setting.

Background alignment: Policy aligns with the IDSA/AAN/ACR 2020 Lyme disease guidelines (favoring serum antibody testing over nonserologic methods except in defined scenarios such as PCR on synovial fluid for seropositive suspected Lyme arthritis) and with CDC Zika testing guidance (targeted NAAT/serologic testing focused on pregnant persons with exposure and fetuses/infants with congenital findings; routine screening of asymptomatic persons is not recommended).

High-level stats and dates

Diseases coveredLyme disease (Borrelia burgdorferi); Zika virus

Supported Lyme serologic indications (count)4 (atypical erythema migrans; suspected neuroborreliosis; suspected Lyme arthritis; acute myocarditis/pericarditis)

Specific PCR scenario count (Lyme)1 (PCR on synovial fluid/tissue when seropositive and needed for treatment decisions in suspected Lyme arthritis)

Supported Zika testing scenarios (count)3 (pregnant with abnormal prenatal ultrasound + exposure; infant ≤12 months with maternal laboratory evidence; infant ≤12 months symptomatic with maternal exposure)

last_review2024-11-24

Medical Necessity Criteria (Lyme disease and Zika virus)

Coding

Lyme / Zika CPT codes (informational)CPT

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
0316U	Borrelia burgdorferi (Lyme disease), OspA protein evaluation, urine
86617	Antibody; Borrelia burgdorferi (Lyme disease) confirmatory test (eg, Western Blot or immunoblot)
86618	Antibody; Borrelia burgdorferi (Lyme disease)
86794	Antibody; Zika virus, IgM
87475	Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, direct probe technique
87476	Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, amplified probe technique
87662	Infectious agent detection by nucleic acid (DNA or RNA); Zika virus, amplified probe technique

Other Lyme tests listed as not supported (informational)mixedNot Covered

0316U

Lyme Borrelia OspA urine evaluation (listed elsewhere as example/test type)

Provider Actions & Documentation Requirements

Documentation Required

Document plausible exposure and clinical signs

Providers must document plausible exposure to Borrelia burgdorferi and the specific clinical indication when ordering Lyme serologic testing. Examples of clinical indications include atypical erythema migrans, suspected neuroborreliosis, suspected Lyme arthritis, or acute myocarditis/pericarditis.

Document plausible exposure to Borrelia burgdorferi
Document specific clinical indication (e.g., atypical erythema migrans; suspected neuroborreliosis; suspected Lyme arthritis; acute myocarditis/pericarditis)

Documentation Required

Document seropositivity and therapeutic decision rationale for Lyme PCR

For Lyme nucleic acid/PCR testing, document that the patient is seropositive for Lyme disease, that Lyme arthritis is suspected, and that PCR results are necessary to inform treatment decisions.

Background and Evidence

This policy is intended for the outpatient setting and is informed by the 2020 joint IDSA/AAN/ACR Lyme disease guidelines and current CDC Zika testing guidance.

For Lyme disease, the policy follows guideline recommendations to prioritize serum antibody testing for specific clinical presentations and to limit nonserologic tests, using PCR primarily as an adjunctive test in defined scenarios (e.g., synovial fluid PCR when seropositive and diagnostic clarity is needed).

For Zika virus, the policy reflects CDC guidance that routine screening is not recommended and that NAAT and/or serologic testing is targeted to pregnant individuals with exposure or abnormal prenatal findings and to infants with maternal linkage or congenital findings.

Guideline / Guidance	Summary Statement
IDSA / AAN / ACR 2020 Guidelines	Recommend serologic (two‑tier) testing for defined clinical presentations (eg, skin lesions suggestive but atypical for erythema migrans; suspected neuroborreliosis; suspected Lyme arthritis; acute myocarditis/pericarditis) and advise against testing in many nonspecific or asymptomatic scenarios; recommend PCR of synovial fluid when seropositive and Lyme arthritis diagnosis/treatment decisions require clarification.
CDC Zika testing guidance (May 15, 2024)	Limits routine testing; recommends targeted NAAT and/or serologic testing for pregnant individuals with exposure and for fetuses/infants with congenital findings or maternal laboratory evidence—does not recommend routine screening of asymptomatic persons or symptomatic non‑pregnant individuals for Zika.

Guideline / Guidance

Summary Statement

IDSA / AAN / ACR 2020 Guidelines

Recommend serologic (two‑tier) testing for defined clinical presentations (eg, skin lesions suggestive but atypical for erythema migrans; suspected neuroborreliosis; suspected Lyme arthritis; acute myocarditis/pericarditis) and advise against testing in many nonspecific or asymptomatic scenarios; recommend PCR of synovial fluid when seropositive and Lyme arthritis diagnosis/treatment decisions require clarification.

CDC Zika testing guidance (May 15, 2024)

Limits routine testing; recommends targeted NAAT and/or serologic testing for pregnant individuals with exposure and for fetuses/infants with congenital findings or maternal laboratory evidence—does not recommend routine screening of asymptomatic persons or symptomatic non‑pregnant individuals for Zika.

Lyme neuroborreliosis: Characterized by cranial or peripheral nerve involvement (e.g., facial palsy, radiculoneuropathy) or central nervous system involvement (meningitis/encephalitis).

Lyme arthritis: Characterized by obvious swelling of one or more joints and joint pain with movement.

Congenital Zika virus infection: Syndrome with severe microcephaly, decreased brain tissue with characteristic damage (including subcortical calcifications), ocular damage, congenital contractures (e.g., clubfoot or arthrogryposis), and hypertonia/restricted movement.

Revision History

revised

Reworded policy statements from 'may be considered medically necessary' to 'are considered medically necessary' for Lyme and Zika test sections. Detail: Minor rewording and formatting with no clinical significance.

03/24revised

Corrected CPT code descriptions and removed CPT 86353 from CPT table. Detail: Coding table updated; removal of 86353 noted as correction.

02/24revised

Added 'lab' to policy title and moved CPT code table into coding implications section. Detail: Formatting and structural changes to policy presentation.