CurrentUnitedHealthcarePolicy N/A

Reimbursement policy for Lyme disease serology and NAAT

Defines UnitedHealthcare Community Plan's reimbursement policy for Lyme disease testing (serologic two-tier testing and nucleic acid techniques) for Medicaid products and applicable claim forms, and specifies conditions under which tests are reimbursable or not.

Policy Summary

PayerUnitedHealthcare Community Plan

PolicyLyme disease serology and NAAT reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims using CMS-1500 or UB-04 forms or electronic equivalents for UnitedHealthcare Community Plan Medicaid products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4procedure codes listed as reimbursable

8clinical conditions supporting reimbursement

8conditions listed for non-reimbursement

1NAAT codes non-reimbursable

Reimbursement and Non-Reimbursement Criteria

Policy Summary

PayerUnitedHealthcare Community Plan

PolicyLyme disease serology and NAAT reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims using CMS-1500 or UB-04 forms or electronic equivalents for UnitedHealthcare Community Plan Medicaid products.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ALL of the following

ALL of the following
- Two-tier serologic testing strategy is used: a sensitive enzyme immunoassay (EIA) or immunofluorescence assay (IFA) followed by a western immunoblot assay or an FDA‑cleared second EIA assay.
ANY 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

ALL of the following

86617 (Lyme disease serologic test – EIA/IFA or first‑tier)
86618 (Lyme disease western immunoblot or second‑tier serology)
0041U (FDA‑cleared second EIA assay)
0042U (FDA‑cleared second EIA assay)

Reimbursable and Non-Reimbursable Codes; Testing Requirements

Reimbursable serology codes (two-tier testing)CPTCovered

86617	Lyme disease serologic test (EIA/IFA or first-tier)
86618	Lyme disease western immunoblot or second-tier serology
0041U	FDA-cleared second EIA assay (as listed)
0042U	FDA-cleared second EIA assay (as listed)

Non-reimbursable NAAT codesCPTNot Covered

87475	NAAT for Borrelia burgdorferi (non-reimbursable per policy)
87476	Related NAAT code (listed as non-reimbursable)

Two-tier testing requirement (inv-04)

RequirementReimbursement considered for a two-tier strategy using a sensitive EIA or IFA followed by a western immunoblot or an FDA-cleared second EIA

When billedApplies when these serologic tests are billed for any of the specified clinical conditions listed in the policy

Test sequenceFirst-tier: sensitive enzyme immunoassay (EIA) or immunofluorescence assay (IFA); Second-tier: western immunoblot OR FDA-cleared second EIA

Claims Submission and Applicability

Documentation Required

Submit accurate claims on CMS-1500/UB-04 (policy scope)

Providers are responsible for submission of accurate claims using the CMS-1500 or UB-04 forms or their electronic equivalents; this policy applies to UnitedHealthcare Community Plan Medicaid products and to all network and non-network providers.

Submit claims on CMS-1500 (1500 Health Insurance Claim Form), UB-04, or electronic equivalents.
Policy applies to UnitedHealthcare Community Plan Medicaid products and to all network and non-network providers, including hospitals, ambulatory surgical centers, physicians, and other qualified professionals.

OpenPayer

Reimbursement policy for Lyme disease serology and NAAT

Reimbursement and Non-Reimbursement Criteria

Reimbursable and Non-Reimbursable Codes; Testing Requirements

Claims Submission and Applicability

Testing Strategy Definitions