CurrentWellCarePolicy N/A

INFECTIOUS DISEASE: VECTORBORNE AND TROPICAL DISEASES LAB TESTING

Clinical coverage criteria for serologic and molecular laboratory testing for Lyme disease (Borrelia burgdorferi) and Zika virus in the outpatient setting; intended for providers and medical necessity determinations for WellCare-affiliated plans.

Policy Summary

PayerWellCare

PolicyVector‑borne and tropical diseases lab testing (Lyme disease, Zika)

Policy CodePolicy N/A

Change TypeCoding editsCPT code removed

Effective DateN/A

Next Review DateN/A

Key ActionDocument clinical rationale supporting testing (exposure, specific signs, serostatus, pregnancy/infant findings) to support coverage decisions.

SourceLink

POLICY UPDATE CHANGES

Corrected CPT code descriptions and removed CPT code 06353.

Added 'lab' to policy title and removed CPT and ICD-10 codes from policy reference table; added CPT code table and moved the 'coding implications' section.

Policy developed and external specialist reviewed with revision and approval dates listed (11/23, 02/24, 03/24).

2diseases covered (Lyme, Zika)

9CPT codes referenced

Severalexplicit non-covered Lyme tests

1CPT code removed (06353)

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.

Coverage Criteria — Lyme Disease and Zika Virus Testing

Lyme Disease Serum Antibody Tests

Covered when ALL of the following are met:

Lyme serum antibody testing (86617, 86618): Member had a plausible exposure to Borrelia burgdorferi

Clinical indication (at least one required): Member has at least one of: (1) skin lesion(s) suggestive of, but atypical for, erythema migrans; OR (2) suspected Lyme neuroborreliosis involving the peripheral or central nervous system; OR (3) suspected Lyme arthritis; OR (4) acute myocarditis or pericarditis.

Lyme Disease NAAT/PCR Tests

Covered when ALL of the following are met:

Lyme NAAT/PCR (87475, 87476): Member is seropositive for Lyme disease

Clinical indication: Member has suspected Lyme arthritis

Clinical necessity: Testing is necessary for making treatment decisions.

Other Non-covered Lyme Disease Tests

Non-covered Lyme tests: The following specific Lyme disease tests are not supported by current evidence: lymphocyte transformation tests; Lyme Borrelia Nanotrap Urine Antigen Test; Lyme ImmunoBlot IgG; Lyme ImmunoBlot IgM.

Zika Virus Nucleic Acid/PCR Tests

Covered when ANY of the following apply:

Zika NAAT/PCR - maternal exposure: Member is pregnant AND had a plausible exposure to Zika virus (e.g., traveled to or lives in an area with transmission or sexual exposure to someone with such travel/residence).

Zika NAAT/PCR - infant: Member is 12 months of age or younger AND either: (1) the mother had laboratory evidence of Zika virus infection during pregnancy; OR (2) the infant has symptoms of congenital Zika virus infection AND the mother had a plausible exposure to Zika virus during pregnancy.

Zika Virus Antibody Tests

Covered when ANY of the following apply:

Zika antibody - maternal with ultrasound findings: Member is pregnant AND prenatal ultrasound findings consistent with congenital Zika virus infection (e.g., microcephaly, ventriculomegaly, corpus callosum abnormalities) AND had a plausible exposure to Zika virus.

Zika antibody - infant: Member is 12 months of age or younger AND either: (1) the mother had laboratory evidence of Zika virus infection during pregnancy; OR (2) the infant has symptoms of congenital Zika virus infection AND the mother had a plausible exposure to Zika virus during pregnancy.

This policy explicitly excludes a number of testing indications that are not supported by current evidence. For Lyme disease, serum antibody testing (86617, 86618) is not supported for asymptomatic patients following a tick bite, for evaluation of erythema migrans, or for a range of neurologic, psychiatric, developmental, and chronic cardiomyopathy presentations listed in the policy (see specific exclusions). Similarly, Lyme NAAT/PCR testing is not supported for indications other than the limited scenario described in the criteria. For Zika virus, both NAAT/PCR and antibody testing are not supported for symptomatic non-pregnant persons or for routine preconception or prenatal screening outside the maternal/infant indications specified in the policy.

When state Medicaid coverage provisions conflict with this clinical policy, the applicable state Medicaid provisions take precedence. Coverage decisions remain subject to the terms of the member's coverage documents and to federal, state, and Health Plan-level administrative requirements.

The policy notes that current evidence does not support many of the listed indications for Lyme disease and Zika virus testing. Specifically, Lyme serum antibody and Lyme NAAT/PCR testing are supported only in narrow, evidence-based scenarios described in the criteria; outside those situations the tests are considered not medically necessary. Likewise, Zika NAAT/PCR and antibody testing are limited to defined maternal and infant indications and are not supported for routine screening or for symptomatic non-pregnant individuals.

Coding and Billing References

Referenced CPT/Proprietary Codesmixed

86617	Antibody; Borrelia burgdorferi (Lyme disease) confirmatory test (eg, Western Blot or immunoblot)
86618	Antibody; Borrelia burgdorferi (Lyme disease)
86794	Antibody; Zika virus, IgM
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
87662	Infectious agent detection by nucleic acid (DNA or RNA); Zika virus, amplified probe technique
0041U	Borrelia burgdorferi, antibody detection of 5 recombinant protein groups, by immunoblot, IgM
0042U	Borrelia burgdorferi, antibody detection of 12 recombinant protein groups, by immunoblot, IgG
0316U	Borrelia burgdorferi (Lyme disease), OspA protein evaluation, urine

Removed CPT CodesCPTNot Covered

06353

CPT code removed

Provider Responsibilities, Documentation, and Billing

Billing Rule

Coding references for authorization

This clinical policy references CPT and proprietary molecular/lab codes for billing and review. Codes included are for informational purposes only and their inclusion or exclusion does not guarantee coverage. Providers should reference the most up-to-date professional coding guidance prior to claim submission.

Reference CPT and proprietary codes when requesting authorization or submitting claims
Inclusion of a code here is informational; verify coverage applicability with plan-level rules

Denial Risk

Lyme serum antibody testing — denial triggers

Lyme disease serum antibody testing (e.g., 86617, 86618) is considered not supported for many indications. Denial risk applies when testing is ordered for indications lacking clinical support such as asymptomatic patients after a tick bite or for classic erythema migrans.

Background — Vector-borne and Tropical Diseases

Vector-borne diseases such as Lyme disease and Zika virus are infections transmitted by arthropod vectors (ticks and mosquitoes, respectively). Risk of exposure depends on geography, seasonality, travel history, and specific epidemiologic factors; these considerations inform the policy's requirement for a plausible exposure before testing. The document focuses on outpatient laboratory testing criteria and aligns testing indications with clinical syndromes (e.g., atypical erythema migrans, neuroborreliosis, Lyme arthritis, maternal prenatal findings, and congenital or infant symptoms) where testing is supported by evidence and necessary for management decisions.

Definitions

inv-22: Lyme neuroborreliosis — definition and clinical features

DefinitionLyme neuroborreliosis is characterized by cranial or peripheral nerve involvement (e.g., facial palsy, radiculoneuropathy) or central nervous system involvement (meningitis/encephalitis).

Typical clinical featuresCranial nerve palsies such as facial palsy; radiculoneuropathy manifesting as limb pain or weakness; meningitis or encephalitis with associated neurologic signs.

Implication for testingConsider serologic testing when clinical picture is consistent with neuroborreliosis as specified in coverage criteria (policy links clinical signs to testing eligibility).

inv-23: Lyme arthritis — definition

DefinitionLyme arthritis is characterized by obvious swelling of one or more joints and joint pain with movement.

Typical clinical features