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Coverage criteria policies

Tick Borne Illness – Laboratory Testing

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

Prior authorization is not required for laboratory testing for tick-borne illness.

Coverage

Lyme Disease

The following diagnostic tests are covered:

  • IgG and IgM by enzyme –linked immunosorbent assay (ELISA) or indirect immunofluoresence assay (IFA)
  • IgG and IgM Western blot

The following tests are considered experimental/investigational and are not covered:

  • C6 Peptide ELISA assay
  • IgA Screen (IFA)
  • Polymerase chain reaction (PCR) for identification or quantification of Lyme disease (B. burgdorferi) spirochetal DNA or RNA
  • 31kDa Epitope Test for IgM
  • Lyme Dot Blot Assay for antigen
  • Borrelia burgdorferi antibody index testing
  • Borrelia culture
  • CD57+ lymphocyte counts
  • Antibiotic provocation testing
  • Serum borreliacidal assay
  • T-cell proliferation response assay
  • Urine antigen assay
Babesiosis

The following diagnostic tests are covered:

  • Antibody for Babesia microti IgG & IgM
  • Antibody for Babesia duncani IgG & IgM
  • Babesia PCR Panel (B microiti & B duncani)

The following test is considered experimental / investigational and is not covered:

  • Babesia FISH (RNA)
Bartonella

The following diagnostic tests are covered:

  • Bartonella henselase PCR – whole blood

The following tests are considered experimental / investigational and are not covered:

  • Bartonella henselae IgG/IGM Antibody
  • Bartonella FISH (RNA)
Erlichiosis

The following diagnostic tests are covered:

  • HME (Monocytic) IgG and IgM antibody
  • HME PCR  – whole blood
  • HGE (Anaplasma phagocytophils) IgG & IgM Antibody
  • HGE PCR – whole blood
Rickettsia

The following diagnostic test is covered:

  • Rickettsia IgG Antibody by ELISA or IFA

The following test is considered experimental/investigational and is not covered:

  • Rickettsia PCR – whole blood

None of the above tests are covered as screening tests or in clinical circumstances in which the pre-test probability of the disease is low.

Definitions

Tick borne illness: A variety of diseases may be spread by ticks. The majority of tick-transmitted diseases result from the bite of an infected blacklegged tick (also known as the deer tick). The most common illness is Lyme disease, also known as borrelia burgdorferi. Other less common illnesses are babesiosis, ehrlichiosis and anaplasmosis.

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

86618

C6 Peptide B. burgdorferi

86618

Lyme IgG/IgM/IgA Screen (IFA)

86618

Lyme Serology IgG/IgM

86618

Lyme Serology IgM

86617

Lyme Western Blot IgM

86617

Lyme Western blot IgG

86617

31kDa Epitope Test IgM

87449

Lyme Dot Blot Assay (1-3 samples)

87449

Multiplex PCR (B. burgdorferi)

86611

Bartonella henselae IfF/IfM Antibody

87471

Bartonella henselase PCR – whole blood

86753

Antibody for Babesia microti IgG & IgM

86753

Antibody for Babesia duncani IgG & IgM

87797-98

Babesia PCR Panel (B microiti & B duncani)

88365

Babesia FISH (RNA)

86317

HME (Monocytic) IgG and IgM antibody

87797-98

HME PCR  – whole blood

86317

HGE (Anaplasma phagocytophils) IgG & IgM Antibody

87797, 87798

HGE PCR – Whole Blood

86757

Rickettsia IgG Antibody

87797-98

Rickettsia PCR – whole blood

Central Nervous System – (Cerebral Spinal Fluid)

Codes

Description

87800-01

Lyme PCR - CSF

87449

Lyme DOT BLOT Assay – CSF

87471

Bartonella henselae

87797-98

Rickettsia PCR - CSF

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. Biggs, H. M., Behravesh, C. B., Bradley, K. K., Dahlgren, F. S., Drexler, N. A., Dumler, J. S. (2016, May 16). Diagnosis and Management of Tickborne Rickettsial Diseases: Rocky Mountain Spotted Fever and Other Spotted Fever Group Rickettsioses, Ehrlichioses, and Anaplasmosis — United States. MMWR Recomm Rep, 65(2):1–44. doi: http://dx.doi.org/10.15585/mmwr.rr6502a1
  2. Brown, S. L., PhD, MPH, Hansen, S. L., PhD, & Langone, J. J., PhD. (1999, July 7). Role of Serology in the Diagnosis of Lyme Disease. The Journal of the American Medical Association, 282(1), 62-66. doi:10.1001/jama.282.1.62
  3. CDC - Lyme Disease Home - Diagnosis and Testing - Laboratory tests that are not recommended.
  4. Retrieved August 2, 2016 from http://www.cdc.gov/lyme/diagnosistesting/LabTest/OtherLab/index.html.
  5. CDC - Lyme Disease Home - Diagnosis and testing - Two-step Laboratory Testing Process. Retrieved August 2, 2016 from http://www.cdc.gov/lyme/diagnosistesting/LabTest/TwoStep/index.html.
  6. Moore, A., Nelson, C., Molins, C., Mead, P., Schriefer, M. (2016 July). Current Guidelines, Common Clinical Pitfalls, and Future Directions for Laboratory Diagnosis of Lyme Disease, United States. Emerging Infectious Diseases, 22(7). doi: http://dx.doi.org/10.3201/eid2207.151694.
  7. Tickborne Diseases of the United States: A Reference Manual for Health Care Providers. Retrieved August 8, 2016 from https://www.cdc.gov/lyme/resources/tickbornediseases.pdf.
  8. Wormser, G. P., Dattwyler, R. J, Shapiro, E. D., Halperin, J. J., Steere, A. C., Klempner, M. S., et al. (2006, October 2.) 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, 43(9),1089–134. doi: 10.1086/508667

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Policy activity

  • 12/20/2010 - Date of origin
  • 12/20/2010 - Effective date
Review date
  • 09/2016

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