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Intravenous Antibiotic Therapy for Lyme Disease
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Notification of new policy. Treatment of lyme Disease consists of oral antibiotics, except for the following indications: A 2-to 4-week course of IV antibiotic therapy may be considered medically necessary (1) in patients with neuroborreliosis with objective neurologic complications of documented Lyme Disease. 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; (2) in patients with Lyme carditis as evidenced by positive serologic findings and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second; (3) 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.
Lyme Disease may be documented either on the basis of serologic testing or examination of the CSF. Positive serologic diagnosis is defined as both (1) positive or indeterminate ELISA test as characterized by IgG showing a titer >800 (positive) or a titer between 1:200 and 1:400 (indeterminate) or IgM ELISA test showing a titer of >200 (positive) or 1:100 (indeterminate) and (2) positive immunoblot or Western blot as characterized by (1) 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. 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.
IV antibiotic therapy for Lyme Disease is considered not medically necessary in the following situations: patients with symptoms consistent with chronic fatigue syndrome or fibromyalgia; patients with seronegative Lyme disease in the absence of CSF antibodies; initial therapy in patients with Lyme arthritis without coexisting neurologic symptoms; patients with vague systemic symptoms without supporting serologic or CSF studies; patients with a positive ELISA test, unconfirmed by an immunoblot or Western blot test; patients with an isolated positive serologic test in the setting of multiple negative serologic studies; repeat or prolonged courses (greater than 4 weeks) of antibiotic therapy.
The following are considered investigational: Repeat PCR-based direct detection of B. burgdorferi as a justification for continuation of IV antibiotics beyond 1 month in patients with persistent symptoms or as a technique to follow therapeutic response; PCR-based direct detection of B. burgdorferi in urine samples; genotyping or phenotyping of B. burgdorferi; CPT codes 87475 and 87477.
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