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Anthem Blue Cross ConnecticutCommercial Clinical Policy

Anthem Blue Cross Connecticut MED.00013 Parenteral Antibiotics for the Treatment of Lyme Disease Form


Parenteral Antibiotics for Lyme Disease

Notes: Coverage is for a course of up to 4 weeks of IV antibiotic therapy.

Indications

(501397) Does the patient have Lyme disease with myocarditis associated with second- or third-degree atrioventricular block, or with first-degree heart block where the PR interval is prolonged to 300 milliseconds or greater? 
(501398) Does the patient have persistent or recurrent joint swelling (arthritis) after an initial 1 month trial of oral antibiotics? 
(501399) Does the patient have acute or chronic neurological disease affecting the central or peripheral nervous system presenting as meningitis? 
(501400) Does the patient have any neurologic syndrome with cerebrospinal fluid (CSF) pleocytosis? 
(501401) Does the patient have severe peripheral neurologic syndromes with normal CSF including radiculopathy, diffuse neuropathy, mononeuropathy multiplex, or cranial neuropathy following treatment failure with oral antibiotic therapy? 

YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

06/28/2023

Last Reviewed

05/11/2023

Original Document

  Reference



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

Position Statement

Medically Necessary:

A course of up to 4 weeks of intravenous (IV) antibiotic therapy is considered medically necessary for individuals with Lyme disease meeting ANY of the following criteria:

  • Myocarditis associated with second- or third-degree atrioventricular block, or with first-degree heart block when the PR interval is prolonged to 300 milliseconds or greater; or
  • Persistent or recurrent joint swelling (that is, arthritis) after an initial 1 month trial of oral antibiotics; or
  • Acute or chronic neurological disease affecting the central or peripheral nervous system, including ANY of the following:
    • Meningitis; or
    • Any neurologic syndrome with cerebrospinal fluid (CSF) pleocytosis; or
    • Peripheral neurologic syndromes with normal CSF (including radiculopathy, diffuse neuropathy, mononeuropathy multiplex, or cranial neuropathy) if severe or following treatment failure with oral antibiotic therapy; or
    • Encephalomyelitis; or
    • Encephalopathy.

And antibiotic used is:

  • Ceftriaxone (Rocephin®), cefotaxime (Claforan®), or Penicillin G; or
  • Azithromycin (Zithromax®) in individuals with betalactam allergy or intolerance.

Investigational and Not Medically Necessary:

Intravenous (IV) antibiotic therapy for individuals with Lyme disease is considered investigational and not medically necessary when criteria are not met, including when the following IV drugs are used:

  • Carbapenems (for example, doripenem, ertapenem, imipenem, meropenem); or
  • First-generation cephalosporins (for example, cefazolin); or
  • Fluconazole; or
  • Fluoroquinolones (for example, levofloxacin, moxifloxacin).

Other indications for intravenous (IV) antibiotic therapy for Lyme disease are considered investigational and not medically necessary, including, but not limited to any of the following:

  • Prophylactic treatment of individuals who have reported a tick bite but have no clinical findings suggestive of Lyme disease; or
  • Treatment of individuals with systemic symptoms without serologic or cerebrospinal fluid (CSF) studies confirming Lyme disease; or
  • Treatment of chronic fatigue syndrome or fibromyalgia attributed to Lyme disease; or
  • Initial treatment of Lyme arthritis without coexisting neurological symptoms; or
  • Treatment of persistent Lyme-associated 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 and not medically necessary.