Coverage for intravenous antibiotic therapy for treatment of Lyme disease is determined according to individual or group customer benefits. A two to four week course of intravenous antibiotic therapy is eligible for the following indications:

1. In patients with Lyme disease with objective neurologic complications of Lyme disease associated with positive serologic and cerebral spinal fluid (CSF) findings.
   
   

   Objective neurologic findings include:

   • Lymphocytic meningitis associated with CSF abnormalities;
   • Bell's palsy or other cranial neuropathy associated with CSF abnormalities;
   • Encephalitis or encephalomyelitis associated with CSF abnormalities;
   • Radiculopathy;
   • Polyneuropathy.
   
   

   Positive serologic diagnosis is defined as BOTH criteria A and B below:

   1. Positive or indeterminate ELISA test, as characterized by:
      
      • IgIG showing a titer greater than or equal to 800 (positive) or a titer between 1:200 and 1:400 (indeterminate); or
      • IgM ELISA test showing a titer of greater than or equal to 200 (positive) or 1:100 (indeterminate).
      
      
   2. Positive immunoblot or Western blot, as characterized by:
      • 2 of the 8 most common IgM antibody bands to spirochetal antigens are present; or
      • 5 of the 10 most frequent IgG antibody bands are present.
      
      

      NOTE:

      All positive or indeterminate ELISA tests must be confirmed with immunoblot.

      
      

      Positive CSF findings include all of the following:

      • Pleocytosis;
      • Evidence of intrathecal production of B. burgdorferi antibodies in CSF; and
      • Increased protein levels.

1. In patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 seconds.
   
   
2. In the small subset of patients with well-documented Lyme arthritis who have such severe arthritis that it requires the rapid response associated with IV antibiotics.
   
   

   Intravenous antibiotic therapy used in the treatment of Lyme disease for indications other than those referenced above should be denied as not medically necessary and, therefore, not covered. A participating, preferred, or network provider cannot bill the member for the denied service.

   NOTE:

   Repeat or prolonged courses (greater than 4 weeks) of intravenous antibiotic therapy are generally not indicated.

Description

Lyme disease (LD) (088.81) is a multisystem inflammatory disease caused by the spirochete Borrelia burgdorferi transmitted by the bite of an infected ixodid tick endemic to Northeastern, North Central, and Pacific coastal regions of the United States. The disease is characterized by stages, beginning with localized infection of the skin (erythema migrans) followed by dissemination to many sites. Manifestations of early disseminated disease may include lymphocytic meningitis, facial palsy, painful radiculoneuritis, atrioventricular nodal block, or migratory musculoskeletal pain. Months to years later, the disease may be manifested by intermittent oligoarthritis, particularly involving the knee joint, chronic encephalopathy, spinal pain, or distal paresthesias. While most manifestations of LD can be adequately treated with oral antibiotics, intravenous (IV) antibiotics are indicated in some patients with neurologic involvement or atrioventricular heart block. However, overdiagnosis and overtreatment of LD is common due to its nonspecific symptoms, lack of standardization of serologic tests, and difficulties in interpreting serologic tests. In particular, patients with chronic fatigue syndrome or fibromyalgia are commonly misdiagnosed as possibly having LD and undergo inappropriate IV antibiotic therapy.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.