Medical Policy Updates

Notification of Policy Revisions Effective August 11, 2008 (Posted May 5, 2008)

Medical Policy	Revision
Intravenous Antibiotic Therapy for Lyme Disease	Item A.2 in the When Covered section revised to read, "Cranial neuropathy, other than uncomplicated cranial nerve palsy, with documented CSF abnormalities." Revised the last sentence in Item C. to read, "Documentation of Lyme arthritis requires either unequivocal serologic studies, or when serologic studies are equivocal, PCR-based direct detection of B. burgdorferi in the synovial fluid." Also added bullet to Item C. with the following statement: "Patients who have persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy should be re-treated with another 4-week course of oral antibiotics or with a 2-4 week course of intravenous ceftriaxone. A second 4-week course of oral antibiotic therapy is recommended for the patient whose arthritis has substantively improved but has not yet completely resolved, reserving intravenous antibiotic therapy for those patients whose arthritis failed to improve at all or worsened. Clinicians should consider waiting several months before initiating re-treatment with antimicrobial agents because of the anticipated slow resolution of inflammation after treatment." The following statements added to the Not Covered section: "Cranial nerve palsy (e.g. Bell’s palsy) without clinical evidence of meningitis" and "Antibiotic-refractory Lyme arthritis (unresponsive to 2 courses of oral antibiotics or to 1 course of oral and 1 course of intravenous antibiotic therapy)." Statement from the American Academy of Neurology added to Policy Guidelines section. References updated. Specialty Matched Consultant Advisory Panel review 3/31/08. Notification given 5/5/08. Effective date 8/11/08.

Medical Policy

Revision

Intravenous Antibiotic Therapy for Lyme Disease

Item A.2 in the When Covered section revised to read, "Cranial neuropathy, other than uncomplicated cranial nerve palsy, with documented CSF abnormalities." Revised the last sentence in Item C. to read, "Documentation of Lyme arthritis requires either unequivocal serologic studies, or when serologic studies are equivocal, PCR-based direct detection of B. burgdorferi in the synovial fluid." Also added bullet to Item C. with the following statement: "Patients who have persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy should be re-treated with another 4-week course of oral antibiotics or with a 2-4 week course of intravenous ceftriaxone. A second 4-week course of oral antibiotic therapy is recommended for the patient whose arthritis has substantively improved but has not yet completely resolved, reserving intravenous antibiotic therapy for those patients whose arthritis failed to improve at all or worsened. Clinicians should consider waiting several months before initiating re-treatment with antimicrobial agents because of the anticipated slow resolution of inflammation after treatment." The following statements added to the Not Covered section: "Cranial nerve palsy (e.g. Bell’s palsy) without clinical evidence of meningitis" and "Antibiotic-refractory Lyme arthritis (unresponsive to 2 courses of oral antibiotics or to 1 course of oral and 1 course of intravenous antibiotic therapy)." Statement from the American Academy of Neurology added to Policy Guidelines section. References updated. Specialty Matched Consultant Advisory Panel review 3/31/08. Notification given 5/5/08. Effective date 8/11/08.