CurrentPremera BluecrossPolicy 15.01.008

Lyme Disease Testing

This policy defines Premera Blue Cross reimbursement coverage for diagnostic testing for Lyme disease, specifying clinical indications where serologic two-tier testing is reimbursable, situations where testing is not reimbursable, noncoverage of nucleic acid detection and repeat serologic testing after prior positive, and noncoverage of other/novel tests or testing of ticks.

Policy Summary

PayerPremera Bluecross

PolicyLyme Disease Testing

Policy CodePolicy 15.01.008

Change TypeNew policycoding updates

Effective DateFeb 6, 2026

Next Review Date

Key ActionDocument symptoms consistent with Lyme disease and travel/exposure to an endemic region when ordering reimbursable two-tier serologic testing; testing must follow a 2-tier strategy (EIA/IFA followed by western immunoblot or FDA-cleared second EIA).

SourceLink

POLICY UPDATE CHANGES

New policy approved October 14, 2025 and effective for dates of service on or after February 6, 2026 following 90-day provider notification.

02/06/26 coding update removed CPT codes 86617 and 86618.

04/01/26 coding update added new CPT code 0615U.

5Main reimbursable clinical presentations listed

9Not reimbursable clinical situations listed

4Specific codes listed

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Coding changes recorded

1Policy effective dates

Coverage Summary

This policy (Routine Test Management Policy - 15.01.008) addresses coverage for diagnostic testing for Lyme Disease Testing (serologic and molecular). Status: CURRENT. Effective date: 2026-02-06; Last review: 2026-04-01. Testing for Lyme disease may be reimbursable when criteria outlined in this policy are met.

Scope summary: This policy defines Premera Blue Cross reimbursement coverage for diagnostic testing for Lyme disease, specifying clinical indications where serologic two-tier testing is reimbursable, situations where testing is not reimbursable, noncoverage of nucleic acid detection and repeat serologic testing after prior positive, and noncoverage of other/novel tests or testing of ticks.

Policy number15.01.008

SubjectLyme Disease Testing (serologic and molecular)

StatusCURRENT

Effective date2026-02-06

Last review2026-04-01

Scope summaryDefines Premera reimbursement for diagnostic testing for Lyme disease, specifying clinical indications where serologic two-tier testing is reimbursable, situations not reimbursable (including nucleic acid detection, repeat serology after prior positive, testing of ticks), and noncoverage of other/novel tests.

Medical-Necessity Criteria

Covered / Reimbursable Testing

Serologic testing using a two-tier strategy is reimbursable when clinical and epidemiologic criteria are met:

Individual has symptoms of Lyme disease AND a history of travel to a region endemic for Lyme (with or without a history of a tick bite)

Serologic testing uses a 2-tier strategy: sensitive EIA or IFA followed by western immunoblot or FDA-cleared second EIA

Or: For individuals with a history of travel to an endemic region, serologic testing is reimbursable in any of the following clinical presentations

Acute myocarditis/pericarditis of unknown cause
Meningitis, encephalitis, or myelitis
Painful radiculoneuritis

Coding

Nucleic acid detection (listed as not reimbursable)CPTNot Covered

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

Proprietary / Other molecular or immunoblot codes (listed in coding table; status neutral/uncertain coverage depending on clinical criteria)mixed

0041U	Borrelia burgdorferi, antibody detection of 5 recombinant protein groups, by immunoblot, IgM (Proprietary test: Lyme ImmunoBlot IgM; Lab/Manufacturer: IGeneX Inc.)
0042U	Borrelia burgdorferi, antibody detection of 12 recombinant protein groups, by immunoblot, IgG (Proprietary test: Lyme ImmunoBlots IgG; Lab/Manufacturer: IGeneX Inc.)
0316U	Borrelia burgdorferi (Lyme disease), OspA protein evaluation, urine (Proprietary test: Lyme Borrelia Nanotrap® Urine Antigen Test; Lab/Manufacturer: Galaxy Diagnostics Inc.)
0615U	Borrelia burgdorferi (Lyme disease), antibody detection of 26 recombinant protein groups, by immunoassay, IGM (new code effective 04/01/26)

Added CPT codeCPTCovered

0615U

New CPT code added April 01, 2026 (description not provided in this part)

Removed CPT codesCPTNot Covered

86617	Removed from policy on 02/06/26
86618	Removed from policy on 02/06/26

Provider Actions

Documentation Required

Clinical and epidemiologic evidence required for serologic testing

Document symptoms consistent with Lyme disease and travel/exposure to an endemic region when ordering reimbursable two-tier serologic testing; testing must follow a 2-tier strategy (EIA/IFA followed by western immunoblot or FDA-cleared second EIA).

Denial Risk

Denial risk for testing in excluded scenarios

Claims for serologic testing for patients with erythema migrans, asymptomatic screening, non-specific symptoms only, certain neurologic/psychiatric conditions, repeat serology after prior positive, nucleic acid detection, or testing of ticks are at risk for denial.

87475
87476

Background & Evidence

Lyme disease is a multisystem inflammatory illness caused by spirochetes of the family Borreliaceae transmitted by infected Ixodes ticks; in North America infection is predominately due to B. burgdorferi. Early localized disease often presents with a characteristic painless erythema migrans (EM) rash and systemic flu-like symptoms; untreated infection can disseminate to affect the heart, joints, and nervous system (neuroborreliosis, Lyme carditis, arthritis) and may lead to post‑treatment symptoms in some patients.

Most laboratory confirmation relies on serologic testing because direct detection methods have limited applications. The standard laboratory confirmation method is two-tier serologic testing: an initial sensitive enzyme immunoassay (EIA) or immunofluorescence assay (IFA) followed, if positive or equivocal, by a confirmatory western immunoblot or an FDA‑cleared second EIA (a modified two‑tiered testing, MTTT). Direct nucleic acid detection (PCR) and other direct methods are of limited sensitivity and have restricted clinical roles.

Evidence

CDC case counts (2022)Over 63,000 reported cases; CDC estimates ~476,000 Americans diagnosed/treated annually

Serology sensitivity early vs lateSensitivity ~50% in early localized infection; approaches 100% in late disease (per systematic review)

EIA: Enzyme immunoassay — the recommended first‑tier screening serologic test for Lyme disease.

Revision History

2025-10-14policy_approved

New policy approved October 14, 2025; Add to Routine Test Management Policy section; testing for Lyme disease in symptomatic and asymptomatic individuals with travel to epidemic regions may be considered reimbursable when policy criteria met. Effective for dates of service on or after February 6, 2026 following 90-day provider notification.

2026-02-06coding_removed

Coding update effective 02/06/26 removed CPT codes 86617 and 86618.

2026-04-01coding_added

Policy Summary

PayerPremera Bluecross

PolicyLyme Disease Testing

Policy CodePolicy 15.01.008

Change TypeNew policycoding updates

Effective DateFeb 6, 2026

Next Review Date

SourceLink

On This Page

Mononeuropathy multiplex including confluent mononeuropathy multiplex

Acute cranial neuropathy

Not Reimbursable / Exclusions

Serologic and other testing NOT reimbursable in the following situations:

Individuals with an erythema migrans (EM) rash; treat clinically rather than test

Screening asymptomatic patients living in endemic areas

Individuals with non-specific symptoms only (e.g., fatigue, myalgias/arthralgias)

Individuals with amyotrophic lateral sclerosis

Individuals with relapsing-remitting multiple sclerosis

Individuals with Parkinson's disease

Individuals with dementia or cognitive decline, or new-onset seizures

Individuals with psychiatric illness

Detection of Borrelia burgdorferi by nucleic acid identification techniques (direct or amplified probe) — not reimbursable

CPT codes 87475 and 87476 represent direct and amplified probe nucleic acid detection and are listed in Coding

For individuals who have previously tested positive for Lyme disease, repeat serologic testing is not reimbursable

Other Not Covered Testing (insufficient evidence)

Tests not meeting coverage due to lack of published evidence

All other testing for Borrelia burgdorferi not described above is not reimbursable

Testing of the individual tick for diagnosis of Lyme disease is not reimbursable

General reimbursement statement

Testing for Lyme disease may be reimbursable when criteria outlined in this policy are met.

Applies to routine test management; coverage and reimbursement subject to member benefit plan limits and conditions

This medical policy does not apply to Medicare Advantage

Policy does not apply to Medicare Advantage

Testing for Lyme disease in symptomatic and asymptomatic individuals with a history of travel to a region with an epidemic of Lyme disease may be considered reimbursable when criteria outlined in this policy are met

New policy effective Feb 6, 2026 per history

Billing Rule

Coding updates

Providers must use updated CPT coding: CPT codes 86617 and 86618 were removed effective 02/06/26 and CPT code 0615U was added effective 04/01/26; claims must reflect current code set.

0615U (added 04/01/26)
86617 (removed 02/06/26)
86618 (removed 02/06/26)

Documentation Required

Medical necessity and benefit verification

Providers must ensure testing meets the policy's clinical criteria and verify member benefit booklet or contact customer service to determine whether benefit limitations apply.

IFA: Immunofluorescence assay — an alternative first‑tier screening serologic test.

EM: Erythema migrans — the characteristic early localized skin lesion of Lyme disease; diagnosis is clinical and testing is not recommended for typical EM.

MTTT: Modified two‑tiered testing — an algorithm that replaces the second‑tier western immunoblot with an FDA‑cleared second EIA (used when cleared by FDA as an acceptable alternative to the traditional two‑tier algorithm).

Coding update effective 04/01/26 added new CPT code 0615U.