CurrentUnitedHealthcarePolicy 2025R8212B

Medicare Advantage Reimbursement Policy — Lyme Disease Serologic Testing

Defines UnitedHealthcare Medicare Advantage reimbursement rules for Lyme disease serology and related testing billed on UB04 (CMS 1450) and CMS 1500 forms for Medicare Advantage plans and participating providers.

Policy Summary

PayerUnitedHealthcare

PolicyMedicare Advantage reimbursement for Lyme disease serologic testing

Policy CodePolicy 2025R8212B

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit two-tier serologic testing claims only for listed clinical presentations; NAAT for Borrelia burgdorferi is non-reimbursable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2-tierpreferred serologic testing methodology

86617/86618/0041U/0042Uexample procedure codes referenced

Not coveredNAAT status

8 groupsreimbursable condition groups

8 groupsnon-reimbursable condition groups

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Reimbursement Criteria for Lyme Disease Serologic Testing

Reimbursement criteria for Lyme testing

UnitedHealthcare will consider reimbursement for Lyme serologic testing (two-tier) when billed for the following clinical presentations.

Reimbursable serology testing must use a two-tier testing strategy: a sensitive enzyme immunoassay (EIA) or immunofluorescence assay (IFA) followed by a Western immunoblot assay or an FDA-cleared second EIA.

Clinical presentations (one or more of the following)

Fever, malaise, chills, fatigue, myalgia
Cough, shortness of breath
Acute myocarditis/pericarditis, cardiomyopathy
Meningitis, encephalitis, or myelitis
Painful radiculoneuritis
Mononeuropathy multiplex, ataxia
Acute cranial neuropathy
Urticaria

Testing is reimbursed only when billed for the above conditions and uses the two-tier serologic testing methodology described.

Procedure Codes and Testing Methodology

Referenced procedure codesCPT

86617	Lyme disease serology (general reference in policy)
86618	Lyme disease serology (listed alongside 86617)
0041U	Specific Lyme testing code listed
0042U	Specific Lyme testing code listed
87475	NAAT for Borrelia - listed as non-reimbursable
87476	NAAT related code mapping

Testing methodology requirement — Two‑tier testing

Required serologic testing approachTwo-tier testing: a sensitive EIA or immunofluorescence assay (IFA) followed by a Western immunoblot or an FDA‑cleared second EIA

Test components (first tier)Sensitive enzyme immunoassay (EIA) or immunofluorescence assay (IFA)

Test components (second tier)Western immunoblot assay or FDA‑cleared second EIA assay

ApplicabilityExpected method for serologic testing when billed for reimbursable clinical indications listed in the policy

Authorization and Billing Actions

Prior Authorization

Authorization Requirements

UnitedHealthcare Medicare Advantage reimbursement policies do not include notations regarding prior authorization requirements. Providers are responsible for submitting accurate claims using the codes that correctly describe the services provided. For information about a specific enrollee's benefit coverage or any plan-specific prior authorization requirements, contact the customer service number on the member's ID card or refer to the enrollee's benefit documents and the plan contract.

No prior authorization noted in this policy — check the member's plan documents for plan-level requirements.
Providers must submit accurate claims using CPT, CMS, or other appropriate coding guidelines that describe the services provided.
Contact member services (number on back of ID card) or the enrollee's benefit coverage documents for any plan-specific authorization rules.

Key Definitions

Two‑tier testing — definition

DefinitionTwo‑tier testing is a 2‑step serologic strategy using a sensitive EIA or IFA as the first tier, followed by a Western immunoblot or an FDA‑cleared second EIA as the confirmatory second tier

PurposeIncrease specificity of Lyme disease serology by confirming initial reactive results with a second, more specific assay

When expectedApplied for serologic testing billed for clinical presentations that meet the policy's reimbursable conditions

NAAT — Nucleic Acid Identification Techniques for Borrelia burgdorferi

DefinitionNucleic Acid Identification Techniques (NAAT) refer to direct or amplified probe methods to detect Borrelia burgdorferi nucleic acid

Reimbursement stanceUnitedHealthcare will not consider reimbursement for detection of Borrelia burgdorferi by NAAT