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Coverage criteria policies

Lyme disease - antibiotic treatment

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative process

Antibiotics for treating Lyme for the first 1-2 months do not require prior authorization.

Prior authorization is not applicable for antibiotic therapy for Lyme disease for longer than two months because it is considered investigational/experimental.

The provider and facility will be liable for payment unless:

  • The provider notifies the member that a specific service has been determined by HealthPartners to be investigational/experimental; and
  • The member signs a waiver agreeing to pay for the specific non-covered service being rendered; and
  • The claim has been billed with a GA modifier indicating such. If the member has signed a waiver agreeing to pay for the specific service then the member will be liable for payment

Coverage

Antibiotics for treating Lyme disease are generally covered for up to two months, and do not require prior approval.

Prolonged antibiotic therapy for more than two months is not covered because it is considered investigational/experimental and is therefore not covered. Prolonged therapy with oral systemic antibiotics has not been shown to be helpful, and is not recommended for patients with chronic symptoms after recommended treatments. Prolonged courses of antibiotics do not improve the outcome of post-Lyme syndrome, and can cause adverse events.

Definitions

Lyme disease is a common tick-borne illness, caused by the bacterium Borrelia burgdorferi. This infection is spread by infected deer ticks.

Lyme disease typically causes a small, red bump (or bull’s eye rash) within a few days. Nervous system and heart problems can occur after several weeks or months. Arthritis symptoms can occur after several months to a few years.

Post-Lyme disease and chronic Lyme disease are often used to describe nonspecific symptoms (such as headache, fatigue and arthralgias) that persist for months after treatment of Lyme disease. An association between these symptoms and Lyme disease has not been shown.

Antibiotic therapy refers to oral treatments such as amoxicillin and doxycycline, and to intravenous treatment such as ceftriaxone. The duration of treatment ranges from 10 days to 28 days, depending on the severity and organ involvement. Patients with Lyme arthritis with symptoms that improve but do not completely resolve may be treated for an additional 28 days. Prolonged antibiotic therapy for more than two months is not covered. Coverage policies for specific antibiotics are listed in the Drug Formulary and by Medical Policies.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

088.81

Lyme disease

J0696

Injection, ceftriaxone sodium, per 250 mg

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America. Clin Infect Dis. (2006) 43 (9): 1089-1134. http://cid.oxfordjournals.org/content/43/9/1089.full.
  2. Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Halperin JJ, Shapiro ED, Logigian E, Belman AL, Dotevall L, Wormser GP, Krupp L, Gronseth G, Bever CT Jr, Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2007;69(1):91-102.
  3. A critical appraisal of "chronic Lyme disease". Feder HM Jr, Johnson BJ, O'Connell S, Shapiro ED, Steere AC, Wormser GP; Ad Hoc International Lyme Disease Group. N Engl J Med. 2007 Oct 4;357(14):1422-30.

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Policy activity

  • 11/30/2011 - Date of origin
  • 11/01/2017 - Effective date
Review date
  • 11/2017

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