CurrentUnitedHealthcarePolicy 2025R8212B

Lyme disease serology and NAAT reimbursement

Defines UnitedHealthcare Medicare Advantage reimbursement policy for Lyme disease serologic testing and nucleic acid identification techniques on claims submitted on UB04 (CMS 1450) or CMS 1500 forms; applies to Medicare Advantage network providers.

Policy Summary

PayerUnitedHealthcare

PolicyLyme disease serology and NAAT reimbursement

Policy CodePolicy 2025R8212B

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate claims on UB04 or CMS 1500 forms; policy does not include prior authorization notation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2-tierrecommended serologic testing strategy

4 codesreimbursable serology codes

2 codesnon-reimbursable NAAT codes

8reimbursable conditions

8non-reimbursable primary conditions

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Lyme disease testing coverage criteria

UnitedHealthcare will consider reimbursement for two‑tier serologic testing when billed for specified clinical conditions; certain primary conditions and nucleic acid identification techniques (NAAT) are not reimbursed.

ALL of the following

Testing strategy
Two-tier testing: a sensitive enzyme immunoassay (EIA) or immunofluorescence assay (IFA) followed by a Western immunoblot assay or an FDA‑cleared second EIA assay.
ALL of the following
- a. Fever, malaise, chills, fatigue, myalgia
- b. Cough, shortness of breath
- c. Acute myocarditis/pericarditis, cardiomyopathy
- d. Meningitis, encephalitis, or myelitis
- e. Painful radiculoneuritis
- f. Mononeuropathy multiplex, ataxia
- g. Acute cranial neuropathy
- h. Urticaria

ALL of the following

86617 — Lyme disease antibody; immunoassay (EIA) screen
86618 — Lyme disease antibody; immunoblot (western blot) confirmation
0041U — Second‑tier Lyme disease EIA (FDA cleared)
0042U — Second‑tier Lyme disease EIA (FDA cleared)

ALL of the following

ALL of the following
- a. Erythema migrans (EM) rash
- b. Screening of asymptomatic patients
- c. Fatigue
- d. Amyotrophic lateral sclerosis
- e. Relapsing‑remitting multiple sclerosis
- f. Parkinson's disease

ALL of the following

UnitedHealthcare will not consider reimbursement for detection of Borrelia burgdorferi by nucleic acid identification techniques (direct or amplified probe).
Non‑reimbursable NAAT procedure codes: 87475, 87476

Reimbursable and Non-Reimbursable Codes

Reimbursable serology codesCPTCovered

86617	Lyme disease antibody; immunoassay (EIA) screen
86618	Lyme disease antibody; immunoblot (western blot) confirmation
0041U	Second-tier Lyme disease EIA (FDA cleared) — listed as paired to 86617
0042U	Second-tier Lyme disease EIA (FDA cleared) — listed as paired to 86617

Non-reimbursable NAAT codesCPTNot Covered

87475	Probe technique for detection of Lyme (NAAT)
87476	Amplified probe technique for detection of Lyme (NAAT)

inv-04: Testing strategy

StrategyTwo-tier testing: a sensitive enzyme immunoassay (EIA) or immunofluorescence assay (IFA) followed by a Western immunoblot assay or an FDA-cleared second EIA assay.

Tier 1 (screening)Sensitive EIA or immunofluorescence assay (IFA).

Tier 2 (confirmation)Western immunoblot assay or FDA-cleared second EIA assay.

Applicable procedure codesSerologic procedure codes (see coding section) are reimbursable when following this 2-tier strategy and billed for listed clinical conditions.

Claims Submission and Provider Requirements

Prior Authorization

Claims submission: use UB04 or CMS 1500; no prior authorization noted

Submit accurate claims using the appropriate form (UB04 / CMS 1450 or CMS 1500). This policy applies to services billed on UB04 forms (CMS 1450) and CMS 1500 forms and is intended to ensure reimbursement is based on the code(s) that correctly describe the services provided. The policy document does not include a prior authorization requirement or notation for these tests.

Use UB04 (CMS 1450) for facility claims or CMS 1500 for professional claims (or electronic equivalents).
Ensure submitted CPT/CMS codes accurately describe the services to align with UnitedHealthcare Medicare Advantage reimbursement methodology.
No prior authorization requirement is specified in this policy for Lyme disease serologic or NAAT testing.

Key Definitions

inv-06: Two-tier testing definition

DefinitionTwo-tier testing is a sensitive enzyme immunoassay (EIA) or immunofluorescence assay (IFA) followed by a Western immunoblot assay or an FDA-cleared second EIA assay.

PurposeReduce false positives by requiring confirmation of initial reactive serology.

Order of testingInitial sensitive EIA or IFA (first tier) → confirmatory Western blot or FDA-cleared second EIA (second tier).

Policy Summary

PayerUnitedHealthcare

PolicyLyme disease serology and NAAT reimbursement

Policy CodePolicy 2025R8212B

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate claims on UB04 or CMS 1500 forms; policy does not include prior authorization notation.

SourceLink

On This Page

OpenPayer

Lyme disease serology and NAAT reimbursement

Lyme Disease Testing Coverage Criteria

Reimbursable and Non-Reimbursable Codes

Claims Submission and Provider Requirements

Key Definitions