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» LymeNet Flash » Questions and Discussion » Medical Questions » BCBS/WellPoint Medical Policy..

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Author Topic: BCBS/WellPoint Medical Policy..
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hope it's cool to post this.. if not, i'll remove it. this is scanned not typed.. i cleaned it up as best i could.

Fax Nov 7 2007 11:25am P002/010

Page 1 of 9

WellPoint MedIcal Policy

Subject: Parenteral Antibiotics for the Treatment of Lyme Disease

Policy #:MED.00013 Current Effective Date:02/05/2007

Status: Reviewed Last Review Date: 12/07/2006


This policy addresses the use parenteral antibiotics (i.e., intravenous and intramuscular) for the treatment of Lyme disease.

Policy Statement

Medically Necessary:

A 4 week course of IV antibiotic therapy usually with ceftriaxone or penicillin is considered medically necessary for patients with Lyme disease meeting ANY of the following criteria:

* Myocarditis associated with third degree heart block; or

* Persistent or recurrent joint swelling (i.e., arthritis) after an initial 1 month trial of oral antibiotics; or

* Acute meningitis or radiculopathy; or

* Late neurological disease affecting the central or peripheral nervous system.

Investigational/Not Medically Necessary:

Other indications for IV antibiotic therapy for Lyme disease are considered investigational/not medically necessary, including, but not limited to ANY of the following:

* Prophylactic treatment of patients who have reported a tick bite but have no clinical findings suggestive of Lyme disease; or

* Treatment of patients with vague systemic symptoms without supporting serologic or cerebrospinal fluid (CSF) studies; or

* Treatment of chronic fatigue syndrome or fibromyalgia attributed to Lyme disease;


* Initial treatment of Lyme arthritis without coexisting neurological symptoms; or

* Treatment of persistent arthritis after 2 prior courses of antibiotic therapy; or

* Treatment of"post-Lyme disease" syndrome; or

* Repeat or prolonged courses (greater than 4 weeks) of intravenous antibiotics.

Intramuscular antibiotics as a treatment of any aspect of Lyme disease are considered investigational/not medically necessary.


Page 2 of 9

Role of IV Antibiotics

A diagnosis of Lyme disease (LD) requires appropriate epidemiologic data, supporting clinical observation (including

exposure to ixodid ticks in an endemic area), and supporting laboratory findings. However, over diagnosis and over treatment

of LD is common (Hu, 1993; Steere, 1993; Am College of Rheumatology, 1993). Intravenous antibiotic therapy in patients

with presumed LD may be inappropriately recommended in the following situations: an incorrect diagnosis; prolonged or

repeated courses of IV antibiotics; and use of IV antibiotics when oral antibiotics are adequate. An incorrect diagnosis of LD

includes those patients with positive serologies without characteristic signs or symptoms of LD, or those with non-

specific symptoms, but with no known exposure to ticks in an endemic area, or those without supporting serologic evidence. In

1993 the American College of Rheumatology published a position paper on IV antibiotic treatment for LD, which

concluded that "empiric treatment of patients with nonspecific chronic fatigue or myalgia on the basis of positive serologic

results alone will result in many more instances of antibiotic toxicity than cures of atypically symptomatic true Lyme disease.

In patients whose only evidence for Lyme disease is a positive immunologic test, the risks for empiric N antibiotic treatment

outweigh the benefits."(Am College of Rheumatology, 1993). Other studies have also supported the use of oral, not IV,

antibiotics in patients with LD without neurologic involvement (Dattwyler 1997; Eckman 1997).

Published literature suggests that IV antibiotic therapy should be limited to those patients with objective and laboratory evidence

of neuroborreliosis, those patients with carditis and third degree heart block, and in those with well-docwnented severe Lyme

arthritis that does not respond to initial oral antibiotic therapy (Rahn, 1991; Paclmer 1995; Sigal, 1992 and 1995; Steere,

1997). No evidence supports prolonged (greater than 1 month) or repeated courses of IV antibiotic therapy. Practice guidelines

regarding the treatment of Lyme disease have been issued by the Infectious Diseases Society of America (2006). These

guidelines induded the following recommendations for IV antibiotics. Note that none of the recommendations suggest

longer than a I-month course of IV antibiotics:

* Meningitis or radiculopathy; 14~28 days

* 3rd degree heart block; 14-21 days

* Recurrent arthritis after oral regimen; 14-28 days

* CNS or peripheral nervous system disease; 14-28 days

In addition, these guidelines recommend symptomatic treatment for symptoms that persist after appropriate antibiotic therapy.

For example, patients with persistent arthritis may be treated with anti-inflammatory agents or arthroscopic synovectomy.

Finally, these guidelines recommend symptomatic treatment for symptoms that persist after

Page 3 of 9

appropriate antibiotic therapy. These guidelines do not identifY any role for intramuscular antibiotics.


Lyme disease (LD) is a multisystem inflammatory disease caused by the spirochete Borrelia burgdorjeri and 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, over

diagnosis and over treatment ofLD is common due to its nonspecific symptoms, a lack of standardization of serologic

tests, and difficulties in interpreting serologic test results. In particular, patients with chronic fatigue syndrome or

fibromyalgia are commonly misdiagnosed as possibly having LD and undergo inappropriate IV antibiotic therapy.

Risk factors in contracting Lyme disease center on people's exposure to outside environments in areas where Lyme disease

occurs. Such activities include working in areas surrounding tick-infested woods and overgrown brush and in outside

occupations. Additionally, people who spend time outside or participate in leisure activities such as hunting, fishing, hiking,

or camping are at high risk for Lyme disease. Any of these activities bring these participants into areas where ticks may be present.

The following paragraphs describe the various manifestations ofLD that may prompt therapy with IV antibiotics.

Neurologic Manifestations of Lyme Disease (Neuroborreliosis)

Lymphocytic meningitis, characterized by head and neck pain, may occur during the acute disseminated stage of the disease.

Analysis of the cerebrospinal fluid (CSF) is indispensable for the diagnosis of Lyme meningitis. If the patient has LD, the CSF will

show a lymphocytic pleocytosis presence of too many cells with increased levels of protein. Intrathecal production of antibodies

directed at spirochetal antigens is typically present. A normal CSF analysis is strong evidence against Lyme meningitis.

Treatment with a 2- to 4-week course of IV antibiotics, typically ceftriaxone or cefotaxime, is reconunended.

Cranial neuritis, most frequently Bell's palsy, may present early in the course of disseminated LD, occasionally prior to the development of antibodies, such that an LD

Page 4 of 9

etiology luay be difficult to rule in or out. While Bell's palsy typically resolves spontaneously with or without treatment with

oral antibiotics, some physicians have recommended a lumbar plli1cture and a course of IV antibiotics if pleocytosis in the CSF

is identified, primarily as a prophylactic measure to prevent further neurologic symptoms.

A subacute encephalopathy may occur months to years after disease onset, characterized by subtle disturbances in memory,

mood, sleep, or cognition accompanied by fatigue. These symptoms may occur in the absence of abnonnalities in the

electroencephalogram (EEG), magnetic resonance imaging (MRI), or CSF. In addition, the symptoms are nonspecific and overlap

with fibromyalgia and chronic fatigue syndrome. Thus diagnosis of Lyme encephalopathy may be difficult and may be best

diagnosed with a mental status exam or neuropsychological testing. However, treatment with IV antibiotics is generally not

indicated unless CSF abnormalities are identified.

Much rarer, but of greater concern, is the development of encephalomyelitis, characterized by spastic paraparesis, ataxias,

cognitive impairment, bladder dysfunction, and cranial neuropathy. CSF examination reveals a pleocytosis and an

elevation in protein. Selective synthesis of anti-spirochetal antigens can also be identified. A course of IV antibiotics with 3

to 4 weeks of ceftriaxone is suggested when CSF abnormalities are identified.

A variety of peripheral nervous system manifestations of LD have also been identified. Symptoms of peripheral neuropathy include

paresthesias, or radicular pain with only minimal sensory signs. Patients typically exhibit e1ectromyographic (EMG) or nerve

conduction velocity abnormalities. CSF abnonnalities are usually seen only in those patients with a coexistent encephalopathy.

Cardiac Manifestations of Lyme Disease

Lyme carditis may appear during the early dissemination stage of the disease; symptoms include atrioventricular heart block,

tachyarrhythmias, and myopericarditis. Antibiotics are typically given, although no evidence proves that this therapy hastens the

resolution of symptoms. Both oral and IV regimens have been advocated. Intravenous regimens are typically used in patients

with a high degree atrioventricular block or a PR interval on the electrocardiogram (EKG) of greater than 0.3 second. Patients

with milder forms of carditis may be treated with oral antibiotics.

Lyme Arthritis

Lyme arthritis is a late manifestation of infection and is characterized by an elevated 19G response to B. burgdoiferi and

intennittent attacks of oligoarticular arthritis, primarily in the large joints such as the knee. Patients with Lyme arthritis may be

successfully treated with a 30-day course of oral doxycycline or amoxicillin, but care must be taken to exclude simultaneous

central nervous system (eNS) involvement, requiring IV antibiotic treatment. In the small subset of patients that do not respond to

oral antibiotics, an additional 30-day course of oral or IV antibiotics may be recommended.

Page 5 of 9

Fibromyalgia and Chronic Fatigue Syndrome

Fibromyalgia and chronic fatigue syndrome are the diseases most commonly confused with LD. Fibromyalgia is characterized

by musculoskeletal complaints, multiple trigger points, difficulty in sleeping, generalized fatigue, headache, or neck pain. The

joint pain associated with fibromyalgia is typically diffuse, in contrast to Lyme arthritis, which is characterized by marked

joint swelling in one or a few joints at a time, with few systemic symptoms. Chronic fatigue syndrome is characterized by

multiple subjective complaints, such as overwhelming fatigue, difficulty in concentration, and diffuse muscle and joint pain. In

contrast to LD, both of the above conditions lack joint inflammation, have normal neurological test results, or have test

results suggesting anxiety or depression. Neither fibromyalgia nor chronic fatigue syndrome has been shown to respond to antibiotic therapy.


Arthritis: inflammation of the joints

Carditis: inflammation of the heart

Chronic fatigue syndrome: a condition of prolonged and severe tiredness or weariness (fatigue) that is not relieved by rest and is not directly caused by other conditions

Fibromyalgia: a common condition characterized by widespread pain in joints, muscles, tendons, and other soft tissues

Lyme disease: Lyme disease is transmitted through the bite of the deer tick (Ixodes scapularis ) infected with the bacteria Borrelia burgdoiferi , which is the actual cause of the disease

Neurological involvement: when a condition involves the nervous system

Prophylactic antibiotic therapy: using antibiotic medications in order to prevent infection when no infection exists


The following codes for treatments and procedures applicable to this policy are included below for infonnational purposes.

Inclusion or exclusion of a procedure, diagnosis or device coders) does not con... .. titute or imply member coverage or

provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine

coverage or non-coverage of these services as it applies to an individual member.

6 of 9

90765 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

90766 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hOUT, up to 8 hours

90767 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour

90768 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion

J0696 Injection, ceftriaxone sodimn, per 250 mg

J2510 Injection, penicillin G procaine, aqueous, up to 600,000 units

S9494 Home infusion therapy, antibiotic, antiviral, or antifungal therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem

S9497 Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 3 hours

S9500 Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours

S9501 Home infusion therapy, antibiotic, antiviral, or antifungal therapy, once every 12 hours

S9502 Home infusion therapy, antibiotic, antiviral, or antifungal therapy, once every 8 hours

S9503 Home infusion therapy, antibiotic, antiviral, or antifungal therapy, once every 6 hours

S9504 Home infusion therapy, antibiotic, antiviral, or antifungal therapy, once every 4 hours

ICD-9 Diagnosis
088.81 Lyme disease (Erythema chronicum migrans)

When services are Investigational/Not Medically Necessary:

For the procedure and diagnosis codes listed above, when
criteria are not met or when the code describes a procedure

indicated in the Policy section as investigational/not medically necessary.

When services may be also InvestigationaUNot Medically Necessary:

Page 7 Qf 9

90772: Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (when specified as intramuscular antibiotic injection)

ICD9 Diagnoses

088.81 Lyme disease (Erythema chronicum migrans)


Peer Reviewed Publications:

1. Hsu VM, Patella SJ, Sigal LH. "Chronic Lyme disease" as the incorrect diagnosis in patients with fibromyalgia. Arthritis Rheum. 1993; 36(11):1493-1500,

2. Steere AC, Taylor E, McHugh GL~ et a1. The overdiagnosis of Lyme disease. lAMA. 1993; 269(14): 1812-1826.

3. Dattwyler RJ, Luft BJ, Kunkel MJ, et a1. Ceftriaxone compared with doxycycline for the treatment of acute disseminated Lyme disease, N Engl J Med. 1997; 337 (5):289-294.

4. Eckman MH, Steere AC, Kalish RA, et a1 Cost effectiveness of oral as compared with intravenous antibiotic therapy for patients with early Lyme disease or Lyme arthritis. N Engl J Med. 1997; 337(5):357-363.

5. Ralm DW, Malawista SE. Lyme disease: Recommendations for diagnosis and treatment. Ann Intern Med. 1991; 114(6):472-481.

6. Pachner AR. Early disseminated Lyme disease: Lyme meningitis. Am J Merl. 1995; 98(4A):30S-43S.

7. Sigal LH. Early disseminated Lyme disease: cardiac manifestations. Am J Med. 1995; 98(4A):25S-29S.

8. Sigal LH. Current recommendations for the treatment of Lyme disease. Drugs, 1992; 43(5):683-699.

9. Steere AC. Diagnosis and treatment of Lyme arthritis. Med Clin North Am. 1997; 81(1): 179-194,

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Collage of Rheumatology. Appropriateness of parenteral antibiotic treatment for patients with presumed Lyme disease. A joint statement of the American College of Rheumatology and the Council of the Infectious Diseases Society of America. Ann Intern Med. 1993; 119(6):518.

2. Wormser GP, Dattwy1er RJ, Schapiro ED, et al. 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; 43:1089-1134.

Page 8 of 9

Web Sites for Additional Information

1. American College of Physicians-American Society of Internal Medicine. Lyme Disease: A patient's guide. Accessed September 19,2006.

2. Centers for Disease Control and Prevention. Lyme Disease Home Page. Accessed September 19,2006.

3. National Lyme Disease risk map. Accessed September 19, 2006.


Antibiotic Therapy

Intravenous Antibiotic Therapy Lyme Disease

Policy History


Reviewed: 12/07/2006 - Medical Policy & Teclmology Assessment Committee (MPTAC) review. No change to policy

position. Coding updated; removed CPT 90780, 90781, 90782 and HCPCS G0347, G0348, G0349, 00350 deleted 12/31/2005.

Revised: 12/11/2005 - MPTAC review. Revised policy title to "Parenteral Antibiotics for the treatment of Lyme Disease";

Removed position language regarding the use of oral antibiotics and laboratory testing; Elaborated on the definition of

neurological involvement in MN section; Added as NMN tx of persistent arthritis. after 2 prior courses of antibiotic therapy and tx of "post-Lyme disease" syndrome.

Revised: 07/14/2005 - MPTAC review. Revision based on policy harmonization: Pre-merger Anthem and Pre-merger WellPoint.

Pre-Merger Organizations/Last Review Date/Policy #/Title

Anthem, Inc: 4/27/2004 MED.00013 Lyme Disease Treatment

WellPoint Health Networks, Inc: 9/23/2004 2.01.05 Lyme Disease (Lyme Borreliosis)

Page 9 of 9

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take

precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member's contract

benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should

be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.

[ 08. November 2007, 04:57 AM: Message edited by: sonicbmx ]

"The hell with Drs.. we have each other!"
My story began here:

Posts: 127 | From Van Nuys, CA | Registered: Aug 2007  |  IP: Logged | Report this post to a Moderator
Honored Contributor (25K+ posts)
Member # 12673

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at first, I thought, well, they'll cover a month of IV.
But I read on . . .

Not allowed:

* Repeat or prolonged courses (greater than 4 weeks) of intravenous antibiotics.

Intramuscular antibiotics as a treatment of any aspect of Lyme disease are considered investigational/not medically necessary.

my thought:

Cancer patients and TB patients get repeated treatment if warranted.

Oh, so sad.

the "experts" (or lack of) listed at the end - interesting.


Posts: 48021 | From Tree House | Registered: Jul 2007  |  IP: Logged | Report this post to a Moderator

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hi sonic, this looks interesting but i can only read those SHORT paragraphs,, NOT those long solid block text.

please edit the LONG SOLID BLOCK PARAGRAPHS ONLY so we can ALL benefit from wht you found!

click on PENCIL/PAPER icon to right of your name, which ill open topic line and body text.

now break it up into sentences for those lengthy 1-sentences so we don't overlook someting important. click edit send when done!

my big thanks to you for other californians to be reading this. [group hug]

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LymeNet Contributor
Member # 12949

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"The hell with Drs.. we have each other!"
My story began here:

Posts: 127 | From Van Nuys, CA | Registered: Aug 2007  |  IP: Logged | Report this post to a Moderator

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