Lyme Disease Testing
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Defines Molina Healthcare's coverage criteria and limitations for laboratory testing used to diagnose Lyme disease, including serologic algorithms, molecular methods, proprietary tests, and tick testing; applies to Molina members per their benefit coverage.
No material clinical or coverage changes in this revision.
Coverage Criteria for Lyme Disease Testing
Lyme testing coverage criteria
Covered when ALL of the following apply:
Covered - Serology
- Individual has symptoms of Lyme disease AND history of travel to or residence in a Lyme-endemic region (with or without a history of tick bite).
Reference: eligible symptomatic presentation plus exposure history
- Serologic testing performed using a two-tier strategy: a sensitive EIA or immunofluorescence assay (IFA) screening test followed by a western immunoblot OR an FDA-cleared second EIA (modified two-tier testing).
Acceptable algorithms: STTT or MTTT
Specific clinical syndromes that also meet coverage
- Acute myocarditis or pericarditis of unknown cause.
- Meningitis, encephalitis, or myelitis.
- Painful radiculoneuritis.
- Mononeuropathy multiplex (including confluent mononeuropathy multiplex).
- Acute cranial neuropathy.
Not covered - Testing scenarios
- Individuals with erythema migrans (EM) rash — treat clinically without serologic testing.
- Asymptomatic screening of patients living in endemic areas.
- Individuals with only non-specific symptoms (e.g., fatigue, myalgias/arthralgias).
- Individuals with amyotrophic lateral sclerosis (ALS), relapsing‑remitting multiple sclerosis, Parkinson's disease, dementia or cognitive decline, new‑onset seizures, or psychiatric illness.
Not covered - Methods and repeat testing
- Detection of Borrelia burgdorferi by nucleic acid identification techniques (direct or amplified probe) does NOT meet coverage criteria.
- Repeat serologic testing for individuals with prior positive Lyme serology does NOT meet coverage criteria.
- Testing of the individual tick does NOT meet coverage criteria.
- Any other Borrelia testing not described as covered above does NOT meet coverage criteria due to insufficient published evidence.
Coverage criteria status
Revision history and status:
Coding and Test Categories
| Two-tier serologic testing (sensitive EIA or IFA screening followed by western immunoblot OR FDA-cleared second EIA assay) described as meeting coverage criteria for symptomatic individuals and specified clinical syndromes when travel to/residence in an endemic region is present. |
| Detection of Borrelia burgdorferi by nucleic acid identification techniques (direct or amplified probe) does NOT meet coverage criteria; repeat serologic testing after prior positive does NOT meet coverage; testing of the tick does NOT meet coverage; other proprietary or non-validated Borrelia tests do NOT meet coverage criteria. |
Provider Actions and Billing Guidance
Coverage determination — apply member benefits and use 2‑tier serology only for specified indications
Apply the member's benefit coverage at the time of the request. Serologic testing using a two‑tier strategy (sensitive EIA or IFA screening followed by western immunoblot OR an FDA‑cleared second EIA) meets coverage criteria only for symptomatic individuals with travel to or residence in a Lyme‑endemic region and for specified clinical syndromes (acute myocarditis/pericarditis of unknown cause; meningitis, encephalitis, or myelitis; painful radiculoneuritis; mononeuropathy multiplex; acute cranial neuropathy). Do not order serologic testing for erythema migrans (treat clinically without testing), asymptomatic screening, non‑specific symptoms alone, repeat serologic testing after a prior positive, nucleic acid detection tests, tick testing, or other Borrelia tests not described as covered.
- Confirm member benefit eligibility and applicable state/federal specifications prior to testing.
- Order only two‑tier serologic testing (EIA/IFA screening → western immunoblot OR FDA‑cleared second EIA) when clinical indications and endemic exposure are present.
- Do not perform serologic testing for patients with erythema migrans; treat clinically without testing.
- Avoid nucleic acid detection techniques, repeat serologic testing after prior positive, tick testing, and other non‑described Borrelia assays — these do not meet coverage.
Coverage update — literature review found no changes to coverage
A literature review completed during the 07/01/2025 policy update did not require any changes to the existing coverage criteria.
Definitions and Abbreviations
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