This version of the policy will become effective 05/21/2018. Policy language was added to include diagnostic services that are Medically Necessary, the intent of the policy remains unchanged. The following CPT codes have been added to the policy: 96365, 96366, 96367, 96368, 99601, 99602, 0041U, 0042U. The following HCPCS codes have been added to the policy: S9494, S9504.
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
A69.21 Meningitis due to Lyme disease
A69.22 Other neurologic disorders in Lyme disease
A69.23 Arthritis due to Lyme disease
A69.29 Other conditions associated with Lyme disease
S9504 Home infusion therapy, antibiotic, antiviral, or antifungal; once every 4 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem