CG-MED-98 Parenteral Antibiotics for the Treatment of Lyme Disease

Policy addresses parenteral (intravenous) antibiotic therapy for Lyme disease. Coverage: up to 4 weeks of IV antibiotics is medically necessary when criteria are met, including any of the following: carditis with first-degree AV block with PR interval ≥300 ms, second- or third-degree AV block; persistent or recurrent arthritis after a 1‑month oral antibiotic trial; or acute/chronic neurologic involvement (e.g., meningitis, neurologic syndrome with CSF pleocytosis, severe peripheral neuropathies after failed oral therapy, encephalomyelitis). IV therapy is not medically necessary when criteria are not met or when using carbapenems, first‑generation cephalosporins, fluconazole, or fluoroquinolones.

"A course of up to 4 weeks of intravenous (IV) antibiotic therapy is consideredmedically necessaryfor individuals with Lyme disease meetingBOTHcriteria AandB below:"

Sign up to see full coverage criteria, indications, and limitations.