Does not apply to TennCare, please refer to the TennCare policy.
DESCRIPTION
Lyme disease is a multisystem inflammatory disease caused by the spirochete Borrelia burgdorferi 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.
The terms post-Lyme disease, post-treatment chronic Lyme disease, and chronic Lyme disease are intended to describe individuals who have had well documented Lyme disease and who remain symptomatic for 6 months or longer after the completion of antibiotic therapy. Based on available literature, the preferred terminology is late Lyme disease.
There is no apparent evidence for the existence of chronic B. burgdorferi infection (Chronic Lyme Disease). Chronic Lyme disease has been deemed a misnomer by experts in this field.
POLICY
Treatments for late Lyme disease are considered not medically necessary.
ADDITIONAL INFORMATION
The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA) documents the following recommendations:
There is no well-accepted definition of post-Lyme disease syndrome. This has contributed to confusion and controversy and to a lack of firm data on its incidence, prevalence, and pathogenesis. In an attempt to provide a framework for future research on this subject and to reduce diagnostic ambiguity in study populations, a definition for post-Lyme disease is proposed. Whatever definition is eventually adopted, having once had objective evidence of B. burgdorferi infection must be a condition sine qua non. Furthermore, when laboratory testing is done to support the original diagnosis of Lyme disease, it is essential that it be performed by well-qualified and reputable laboratories that use recommended and appropriately validated testing methods and interpretive criteria. Unvalidated test methods (such as urine antigen tests or blood microscopy for detection of Borrelia species) should not be used.
To date, there is no convincing biologic evidence for the existence of symptomatic chronic B. burgdorferi infection among patients after receipt of recommended treatment regimens for Lyme disease. Antibiotic therapy has not proven to be useful and is not recommended for patients with chronic (>/= 6 months) subjective symptoms after administration of recommended treatment regimes for Lyme disease.
SOURCES
American Academy of Neurology. (2007, July). Practice parameter: treatment of nervous system lyme disease (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Retrieved January 13, 2009 from http://www.neurology.org/cgi/rapidpdf/01.wnl.0000265517.66976.28v1.pdf.
Auwaeter, P.G. (2007). Point: antibiotic therapy is not the answer for patients with persisting symptoms attributable to lyme disease. Clinical Infectious Diseases. 45 (2), 143-148.
BlueCross BlueShield Association. Medical Policy Reference Manual. (7:2008).Intravenous antibiotic therapy and associated diagnostic testing for lyme disease (5.01.08). Retrieved January 12, 2008.
Centers for Disease Control and Prevention. (2008, October). Lyme disease treatment and prognosis. Retrieved January 13, 2009 from http://www.cdc.gov/ncidod/dvbid/lyme/ld_humandisease_treatment.htm.
Feder, Jr., H.M., Johnson, B.J.B., O’Connell, S., Shapiro, E.D., Steere, A.C., Wormser, G.P., et al. (2007). A critical appraisal of “chronic lyme disease”. The New England Journal of Medicine, 357 (14), 1422-1430.
Klempner, M.S., Hu, L.T., Evans, J., Schmid, C.H., Johnson, G.M., Trevino, R.P. et al. Two controlled trials of antibiotic treatment in patients with persistent symptoms and a history of lyme disease. New England Journal of Medicine, 345 (2), 85-92.
National Institutes of Health. National Institute of Allergy and Infectious Disease (NIAID). (2001, June). Clinical alert: chronic lyme disease symptoms not helped by intensive antibiotic treatment. Retrieved January 6, 2009 from http://www.nlm.nih.gov/databases/alerts/lyme.html.
Wormser, G.P., Dattwyler, R.J., Shapiro, D., Halperin, J.J., Steere, A.C., Klempner, M.S., et al (2006). The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clinical Infectious Diseases 42 (9), 1089-1134.
ORIGINAL EFFECTIVE DATE: 5/9/2009
MOST RECENT REVIEW DATE: 5/9/2009
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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