Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease

This policy covers intravenous antibiotic therapy and associated diagnostic testing for Lyme disease, including treatment of neuroborreliosis with objective neurologic complications, lymphocytic meningitis, cranial neuropathy (excluding uncomplicated palsy), encephalitis/encephalomyelitis, radiculopathy, polyneuropathy, Lyme carditis with high‑degree AV block or PR >0.3 s, selected severe Lyme arthritis, and related diagnostic PCR/serologic testing. Coverage requires that therapy be medically necessary and consistent with authoritative sources and the member’s benefit plan, with required documentation of Lyme infection (positive ELISA plus immunoblot or erythema migrans clinical diagnosis; CNS disease requires CSF pleocytosis, intrathecal B. burgdorferi antibody production and elevated protein or CSF PCR during the early antibody‑window), IV antibiotics are generally limited to a single 2–4 week course for specified indications, and off‑label/experimental use is allowed only when drugs are FDA‑approved for an indication.