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Case History Document



Logan, et al V Empire Blue Cross and Blue Shield
Entered By: Marc C Gabriel/LymeNetDate Created: 10/25/97
Document Type: Other
Title: EMPIRE BLUE CROSS AND BLUE SHIELD MEDICAL POLICY FOR LYME DISEASE

This lawsuit was brought on behalf of six chronically ill Lyme Disease patients, five of whom are patients of either Dr. Kenneth Liegner or Dr. Joseph Burrascano. All six of these patients have been denied pre-authorization for prescribed antibiotic treatment for their illnesses by Empire Blue Cross/Blue Shield. All of the plaintiffs purchased their medical plans privately and their claims are not covered or restricted by the federal ERISA law (which imposes restrictions on the types of damage which can be recovered).

In the course of pre-trial discovery, a Notice for discovery and Inspection of Empire's Lyme Disease Medical Policy was served upon Empire's attorney. The document to follow was produced in response to that pre-trial discovery demand and sets forth the criteria that has been used by Empire when deciding whether it will pay for prescribed treatment of Lyme Disease:
EMPIRE BLUE CROSS AND BLUE SHIELD
MEDICAL POLICY
SUBJECT

Lyme Disease Treatment


DATE

December 8, 1995
Effective Date: Immediately and retroactive to claims under review


POLICY NUMBER

2145

COVERED CPT PROCEDURE CODES

86617 - Borrelia burgdorferi (Lyme disease) confirmatory test (e.g., Western blot or immunoblot)

86618 - Borrelia burgdorferi (Lyme disease) - listed with codes described by CPT as qualitative or semiquantitative immunoassays performed by multistep methods.

RELATED CPT PROCEDURE CODES

83898 - Nucleic acid probe with amplification, e.g., polymerase chain reaction (PCR)

83912 - interpretation and report

84181 - Western Blot, with interpretation and report, blood or other body fluid

84182 - Western Blot, with interpretation and report, blood or other body fluid, immunologic probe for band identification, each.

90780 - I.V. Infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour

90781 - each additional hour, up to 8 hours

LOCAL CODES FOR HOME ANTIBIOTIC THERAPY

X6060 - Home antibiotic therapy

X6062 - Antibiotic therapy, daily (per diem) rate

- See "General Guidelines for Coding TPN and other Supplies" in the Precomputer Manual for coding instructions.

COVERED ICD-9 DIAGNOSIS CODE

088.81- Lyme Disease


DESCRIPTION

Lyme disease is an infectious disease caused by a bacterium that is spread by an insect, the deer tick. It can cause a large number of symptoms including rashes, arthritis, and neurological symptoms. The coverage issue concerns the long term use of intravenous antibiotic therapy in the treatment of Lyme disease.


POLICY

Medical Necessity/Appropriateness

Intravenous antibiotic therapy for Lyme disease is regarded as medically necessary only in certain subgroups of Lyme disease patients. These are:

Disseminated early infection:
- Meningitis
- Radiculoneuritis
- High-degree (2 or 3) atrioventricular heart block

Late infection:
- Persistent arthritis
- Neurologic: meningoencephalopathy or radiculoneuropathy

Objective evidence of these Lyme disease manifestations must be documented. See "Medical Policy Background" and "Documentation Requirements" that follow.

Also see the "Utilization Parameters" section for specific guidelines on the maximum number of services allowed.

All proposals for treatment of Lyme disease with intravenous antibiotics require medical necessity preauthorization. The information listed in the section "Documentation Requirements", or a completed "Statement of Medical Necessity" (see attachment), must be sent to the nurse case management unit (Albany) prior to Initiating treatment for every Lyme patient who is requesting benefits coverage for such treatment.

Claims which have not been preauthorized should be denied.

Coding Guidelines

Diagnostic Testing

The following diagnostic tests are generally accepted tests to assist in the clinical diagnosis of Lyme disease:

- enzyme linked immunosorbent assay (ELISA or EIA)
- immunofluorescent assay (IFA)
- indirect ELISA or capture EIA
- immunoblotting (Western blotting)


Current recommendations are to perform two stage testing (ELISA/EIA or IFA -86618) followed by Western immunoblotting (86617), if the ELISA/EIA or IFA are positive or equivocal. Therefore, claims for both tests on one service date are payable.

-Only CPT 86617 is acceptable for confirmatory Western immunoblotting.

- If codes 84181 and 84182 are reported together (in any combination) with the diagnosis of Lyme disease, the charges should be combined and only code 86617 should be covered.

- Repeated Lyme disease testing, especially through different labs, is generally not medically necessary. See "Utilization Parameters" for specific guidelines.

- Other testing methods such as PCR, T-Cell lymphoproliferative assay, are being studied but are not yet accepted into clinical use and should be regarded (and denied) as "investigational".

-Testing methods other than those listed in this section are not covered and should be denied as "investigational". Codes 83898/83912 are investigational for a diagnosis of Lyme Disease (088.81)

UTILIZATION REVIEW PARAMETERS

Repeated Lyme Disease Testing

-Cases with submitted charges that exceed 8 tests (86617 and 86618 in any combination) in a six month period, should be reviewed with the required documentation to determine medical necessity. See detail regarding diagnostic testing in "Medical Policy Background" section that follows.

Intravenous Antiobiotic Therapy

-Intravenous antibiotic therapy (90780) for Lyme disease can be covered for up to a maximum of 30 days (one month), when such therapy has been determined to be medically necessary, There is no medical/scientific basis for prolonged courses of antibiotic therapy that exceeds this duration. See Table 2- "Summary of Indications for IV Antibiotics" for duration of therapy guidelines.

-The circumstances in which more than one complete course of intravenous antibiotic therapy is medically justified are rare. These circumstances are outlined in the Medical Policy Background section (under Treatment, Late Stage).


DOCUMENTATION REQUIREMENTS

1. For preauthorization review, the attached information request, "Statement of Medical Necessity", should be completed with copies of supportive documentation attached (lab reports, etc.), as required. The key elements of the information required for review are also listed here for retrospective review.

2. For individual case review, medical records or a detailed summary of medical course must be supplied and include the following, including specific dates of key events (diagnosis, treatment, etc.):

- Description of initial exposure, details of initial (early) infection if case at hand regards late manifestations of Lyme disease.

- All prior treatment, including specific drug(s) used, route of administration (oral or intravenous), duration of each course of therapy, treatment results, and treatment side effects.

- Supportive laboratory testing, especially Lyme serologic testing performed at each stage of treatment

- Detailed history and physical relevant to current need for intravenous antibiotic (or other) therapy that provides objective evidence of ongoing manifestations of Lyme infection. This should include all exams by consultants (e.g., neurology, infectious disease, orthopedics), laboratory testing (Lyme serology, tests evaluating other diseases, CSF analysis, etc.), neuropsychological tests (for chronic neurologic Lyme infection), EMG/NCV studies, and imaging studies, when appropriate.

Medical Policy Background Disease Characteristics:

Disease Characteristics:

Lyme disease is an infection that results from the spirochete bacterium Borrellia burgdorferi that is transmitted to humans by the bite of a deer tick. Lyme disease was first described as a distinct entity in the US in 1977 because of a clustering of cases resembling juvenile rheumatoid arthritis around Lyme, Connecticut. Lyme disease is now the most common insect borne infection in the United States. The infection usually begins with flu-like or meningitis like symptoms accompanied by a characteristic rash, termed erythema migrans, at the site of the tick bite. After days to weeks, the spirochete often disseminates from the skin and can effect multiple organ systems, most commonly the joints, nervous system and heart. Months to years later, intermittent attacks of arthritis commonly develop, and in some patients, chronic joint, neurologic, or skin involvement may occur years after disease onset. In rare instances, infection may affect other organ systems and has been associated with a wide range of clinical manifestations.

Most cases have been reported in the coastal northeast between Maryland and Massachusetts, in the upper Midwest Wisconsin and Minnesota) and in the west (California and Oregon). There is no gender or age predilection for the illness. People whose occupations or recreational activities involve exposure in grassy or wooded tick-infested areas are at increased risk of acquiring Lyme disease.

Diagnosis:

The diagnosis of Lyme disease is based primarily on the presence of a characteristic clinical picture, exposure in an endemic area, and an elevated antibody response -to B. Burgdorferi. In the absence of typical clinical manifestations or exposure in an endemic area, one should consider alternative diagnoses regardless of the results of diagnostic tests. The Centers for Disease Control (CDC) criteria for Lyme disease case reporting include:

Presence of erythema chronicum migrans (the typical expanding bull's eye rash at the site of the tick bite)

OR

Musculoskeletal system: recurrent brief attacks of objective joint swelling in one or a few joints, sometimes followed by chronic arthritis in one or a few joints. Not considered as criteria for diagnosis are: chronic progressive arthritis not preceded by brief attacks; chronic symmetrical polyarthritis; arthralgias, myalgias, or fibromyalgia syndromes alone.

Nervous system: Lymphocytic meningitis, cranial neuritis (particularly facial palsy), radiculoneuropathy, or encephalomyelitis. Encephalomyelitis must be confirmed by showing antibody production in the cerebrospinal fluid (CSF) by demonstrating a higher titer of antibody in the CSF than in serum. Not considered as criteria for diagnosis are:
headache, fatigue, paresthesias, or mild stiff neck alone.

Cardiovascular: Acute onset, high grade (2nd or 3rd degree) atrioventricular conduction defects that resolve in days to weeks, sometimes associated with myocarditis. Not considered as criteria for diagnosis are: palpitations, bradycardia, bundle branch block, or myocarditis alone.

Serologic Testing:

In October, 1994, the Second National Conference on Serologic Diagnosis of Lyme Disease issued recommendations for Lyme disease test performance and interpretation. This conference included a number of professional, research, and regulatory groups including the NIH, FDA, and the CDC. Their recommendation was that a two test approach for active disease and previous infection detection be adopted. This should involve initial testing using a sensitive enzyme immunoassay (EIA) or immunofluorescent assay (IFA) followed by a Western immunoblot. All specimens that are positive or equivocal by a sensitive EIA or IFA should be tested by a standardized Western immunoblot. Specimens negative by a sensitive EIA or IFA need not be tested further.

When Western immunoblot is used during the first 4 weeks of disease (early Lyme disease) both IgM and IgG procedures should be done. A positive IgM test result alone is not recommended for use in determining active infection in persons with illness > 1 month's duration because the likelihood of a false positive result is high. If a patient with suspected early Lyme disease has a negative serology, serologic evidence is best obtained by testing of paired acute and convalescent phase serum samples. Serum samples from persons with disseminated or late-stage Lyme disease almost always have a strong IgG response to Borrelia burgdorferi antigens.

It was recommended that an IgM Western immunoblot be considered positive if two or more of the following three bands are present (designated by the unit of measure, kiloDaltons, kDa, the molecular weight of the protein band). Each band represents a specific protein component of the Borrellia burgdorferi organism:

24 (or 21 dependent on the strain being tested)
39
41

It was also recommended that IgG Western immunoblot be considered positive if five of the following 10 bands are present (also in kDa):

18
21 (or 24, dependent on the strain being tested)
28
30
39
41
45
58
66
93


These tests may also be used to detect leptomeningeal production of antibodies in the CSF in patients with suspected neurologic involvement. However the finding of IgG antibody in the spinal fluid may be the result of passive diffusion from the serum. The amount of specific antibody in the serum and CSF must be compared (CSF antibody concentration must exceed the serum concentration to be suggestive). Patients with Lyme meningitis usually have intrathecal (CSF) antibody production, but as with serum antibodies, IgG and IgM may persist for years in some, even after antibiotic treatment.

Efforts to standardize testing methods continue, however there remains considerable potential for false positive/false negative and interlaboratory variability in EIA/ELISA results. The criteria for Western immunoblotting are described in the conference document as "interim,, subject to further refinement of protein identification and techniques that will allow consistency. Though this testing protocol represents a forward step towards consistent testing and reporting methodology, it does not imply that use of these tests can be taken as sole evidence for the presence of clinical Lyme disease.

Polymerase chain reaction PCR) is a technique that can detect the presence of small amounts of DNA in various body fluids or tissue specimens. PCR has been used to detect B. burgdorferi DNA from various sources, however the sensitivity of PCR in published reports appears to vary dependent on the DNA segment chosen for PCR targeting and on the body fluid testing. There is also risk of contamination leading to false positive tests such that positive PCR tests must be interpreted with caution. PCR has not advanced to general clinical use.

The T-cell lymphoproliferative assay detects the cellular immune response to B. Burgdorferi. Its potential use may be in a small percentage of patients in whom late manifestations of the disorder still develop despite antibiotic therapy during the first several weeks of infection. Results have been inconsistent and many healthy controls have had positive results in published reports. T-cell lymphoproliferative assay has limited potential utility, and has not advance to general clinical use.

Clinical Stages of Lyme Disease:

The clinical manifestations of Lyme disease can be divided into those that occur early, within days to a few months following the bite of an infected tick, and those that occur late, generally months to years after the bite. Early stage disease is further divided into localized and disseminated "sub-stages". It is clear that the majority of symptoms and signs associated with both early and late Lyme disease are the result of direct invasion of various organs and tissues by B. burgdorferi. It is not clear, however, whether all of the symptoms and signs of this illness, particularly the chronic neurologic and musculoskeletal manifestations, are the result of the persistence of microorganisms in the tissues. This latter concept is extremely important in the evaluation of prolonged duration or repeated courses of therapy.

The conceptual division of Lyme disease into early and late infection also assists the evaluation and recommendations for therapy. The following table summaries the clinical manifestations that have been noted with each stage of infection.
Table 1. Manifestations of Lyme Disease by Stage. Systems are listed from the most to the least commonly affected.
System
Localized Early Infection
Disseminated Early Infection
Late Infection
Skin
Erythema migrans
Secondary annular lesions, malar rash, diffuse erythema or urticaria, evanescent lesions, lymphocytoma
Acrodermatitis chronica atrophans, localized scleroderma-like lesions
Musculoskeletal
Migratory pain in joints, tendons, bursae, muscle, bone; brief arthritis attacks; myositis*; osteomyelitis*; panniculitis*
Prolonged arthritis attacks, chronic arthritis, peripheral enthesopathy, periostitis or joint subluxation below lesions of acrodermatitis
Neurologic
Meningitis, cranial neuritis, Bell's palsy, motor or sensory radiculoneuritis, subtle encephalitis, mononeuritis multiplex, myelitis*, chorea*, cerebellar ataxia*
Chronic encephalomyelitis, spastic paraparesis, ataxic gait, subtle mental disorders, chronic axonal polyradiculopathy, dementia*
Lymphatic
Regional lymphadenopathy
Regional or generalized lymphadenopathy, splenomegaly
Heart
Atrioventricular nodal block9 myopericarditis, pancarditis
Eyes
Conjunctivitis, iritis*. Choroiditis* hemorrhage or detachment*. panophthalmitis*
Keratitis
Liver
Mild or recurrent hepatitis
Respiratory
Nonexudative sore throat, nonproductive cough, adult respiratory distress syndrome*.
Kidney
Microscopic hematuria or proteinuria
Genitourinary
Orchitis*
Constitutional
Minor
Severe malaise and fatigue
Fatigue

* Indicates manifestations that have been reported, but are rare and limited to one or a few case reports.

Treatment:

All stages of Lyme disease can usually be treated effectively with antibiotic therapy, although most untreated patients eventually recover antibiotics hasten the resolution of symptoms, and appropriate treatment of early Lyme disease prevents the development of the illness. Again, it is important to emphasize that some patients may not recover completely. The recommended treatment of Lyme disease depends on the clinical manifestations and the stage of illness.

Early stage:

Early, localized infection is treated with oral antibiotics. In the absence of meningitis, radiculoneuritis, or high-degree atrioventricular block, early disseminated infection can usually be treated successfully with oral antibiotics. With the exception of residual fatigue, symptoms usually disappear within the 14 to 30 day period of treatment. Patients with meningitis, radiculoneuritis, and high-degree (2nd or 3rd) AV block seem to require intravenous therapy. First degree AV block and isolated Bells (facial, or seventh cranial nerve) palsy can be managed with oral antibiotics as both manifestation resolve even without treatment.

Late stage:

Although the late manifestations of Lyme disease can also be treated successfully with antibiotic therapy, the duration of treatment may need to be longer, the response is often slower, and the likelihood of treatment failure is greater. For patients with late (persistent) arthritis, oral antibiotics are successful in a majority of cases, however recurrence or appearance of other late manifestations may still occur. Intravenous antibiotic treatment of persistent Lyme arthritis lessens the chance of recurrence or progression, but does not eliminate this risk entirely. Persistence despite complete and appropriate therapy has been associated with the presence of histocompatibility antigen HLA-DR4. This raises suspicion that certain patients may be predisposed to a reactive, persistent arthritis on a genetic basis. In summary, Lyme arthritis can usually be treated successfully with oral antibiotics for 30 days. In patients who do not respond, it is reasonable to retreat with oral antibiotics or a 2 to 4 week course of intravenous ceftriaxone.

The late neurologic manifestations of Lyme disease can also be successfully treated with intravenous antibiotic therapy, but the response is slow. It is important to note that improvement in late neurologic Lyme manifestations occurs over a period of months following a course of therapy. Improvement is noted over a 2 to 6 month (or longer) period following treatment. Current recommendations are for a 1 month course of intravenous ceftriaxone for patients with chronic neurologic manifestations of Lyme disease. Improvement of symptoms while on antibiotic therapy, with rapid recurrence as soon as antibiotic therapy is stopped is not typical of the course taken by
true neurologic Lyme disease. Occasionally, true relapse of late objective neurologic Lyme manifestations occur. In such cases, retreatment with a second 1 month course of intravenous ceftriaxone is warranted. However, true recurrence of active neurologic infection with B. burgdorferi is rare, and should be accessible by objective evidence of active infection or neurologic dysfunction

There is nothing in the Lyme disease scientific literature that supports the practice of treating until symptoms disappear. There is also nothing in the literature that supports following prolonged intravenous treatment (many months) with a longer period of continued oral antibiotic therapy, or the use of alternate (other than penicillin or ceftriaxone) or combination intravenous antibiotic regimens. Long term antibiotic therapy can also be associated with serious toxicities such as pseudomembranous colitis, biliary sludging (leading to cholescytectomy), cytopenias/coagulation disorders, and intravascular line-related sepsis.

Though several early case report suggested the possible transmission of B. burgdorferi transplacentally from mother to fetus, epidemiologic and laboratory study have not shown that this occurs. Currently, recommendations are that pregnant women need not be treated differently form other patients except that they should not receive tetracycline. Healthy newborns, born to women who were treated for Lyme disease during pregnancy do not need additional antibiotic therapy. Newborns of women not treated during pregnancy should be observed with a high index of suspicion, but if ill, are much more likely to have a diagnosis other than Lyme disease.

There are a number of possible explanations for the persistence of symptoms after treatment:
  • Inadequate or improper prior therapy. Prior treatment must be reviewed in detail. True lack of response to prior appropriate therapy rare, but requires re-treatment if it occurs.
  • Permanent tissue damage. Damage from infection may result in permanent dysfunction that cannot be altered by antibiotic therapy.
  • Continued inflammation due to immunologic activity that was initiated by infection, or "foreign" material from non-living organism.
  • Slowly resolving Lyme disease. Though the expectation is immediate resolution of symptoms, lingering symptoms of a non-specific nature for six months or more is common.
  • Factors related to any chronic illness. Post-Lyme disease fibromyalgia (non-inflammatory myalgias and arthralgias) is a recognized phenomenon that will not respond to antibiotic therapy. Chronic fatigue syndrome may also follow appropriately treated Lyme disease.
  • Possible immune phenomena following Lyme disease. Infection activates the immunomodulatory system, and in some individuals may act as the stimulus for ongoing immune activity that results in autoimmune reactivity on testing.
  • Unrelated to Lyme disease. Illnesses may be misdiagnosed as Lyme disease especially in endemic areas where it may become common for patients with nonspecific symptoms to be tested (often repeatedly) for Lyme serology. False positive test rates are significant in endemic areas. Lack of laboratory standardization, interlaboratory variability, and even day to day fluctuations of circulating immunoglobins make the likelihood of a positive result a certainty if testing is repeated sufficient times.


    Intravenous antibiotic regimens currently recommended in published recommendations for Lyme disease treatment include:

    Adults:
    Ceftriaxone 2 gm/day IV
    Penicillin G 20 million units/ day, 6 divided doses daily

    Children:
    Ceftriaxone 75 - 100 mg/kg/day
    Penicillin G 300,000 units/kg/day IV, 6 divided doses daily

    (These doses are provided for reference purposes only, and are not intended to be limits of coverage policy.)
    The following table summarizes the Lyme stage/manifestation and the required confirmatory findings that would substantiate the medical necessity of treating Lyme disease manifestations with intravenous antibiotics.

    Table 2. Summary of Indications for IV Antibiotics. For all the following, three conditions must be satisfied:

    1. Characteristic exposure/epidemiologic, and early localized disease history,
    2. Positive Lyme serology confirmed with Western immunoblot,
    3. Exclusion of other common medical illness that can explain clinical findings.
    Early Disseminated Stage
    Manifestations:
    Confirmatory findings required:Duration of therapy (per published recommendations)
    Meningitis1. Clinical signs and symptoms similar to those of aseptic (viral)
    meningitis.
    2. CSF analysis showing lymphocytic pleocytosis (usually = 100 cells/cc), mild protein elevation, normal glucose. 3. CSF serology demonstrative of meningeal antibody production (optional if #2 met)
    14 to 30 days
    Radiculoneuritis1. Asymmetric radiculoneuropathy, motor, sensory, or mixed, affecting limbs, trunk, or both.
    And/or
    Cranial neuropathy OTHER THAN isolated peripheral 7th nerve (facial, Bell's) palsy
    Confirmed by:
    a. Detailed neurologic physical exam, preferably by a neurologist, or
    b. EMG/NCV studies.
    14 - 30 days
    2 or 3 AV block (cardiac)1. Characteristic electrocardiographic findings, often fluctuating in degree
    And/or
    Carditis (rare)
    1O-30 days
    Late Stage
    Manifestations:
    Confirmatory findings required:Duration of therapy (per published recommendations)
    Persistent arthritis1. Recurrent attacks of asymmetrical oligoarticular arthritis joint effusion and pain, not arthralgia, alone), most commonly the knee
    2. Prior treatment of Lyme arthritis with 30 day course of appropriate oral antibiotic therapy.
    14-30 days
    Neurologic/encephalomyelitis1. Objective evidence of neurological dysfunction as documented by either:
    -Neurologic physical exam
    -Organic deficit demonstrable by neuropsychological testing
    -MRI showing small round areas of increased ~ signal intensity in peripheral white matter.
    OR
    2. Continued evidence of intrathecal antibody production to B. burgdorferi.
    OR
    3. CSF analysis showing lymphocytic pleocytosis
    30 days
    Neurologic/radiculoneuritis1 Objective evidence by neurologic physical exam or EMG/NCV studies of polyneuropathy.
    Suggestive/not required:
    2. Continued evidence of intrathecal antibody production to B. burgdorferi or other CSF abnormalities.
    3. Sural nerve biopsy showing axonal injury with perivascular lymphoplasmacytic infiltrates.
    30 days

    Lyme Disease - Statement of Medical Necessity for IV Antibiotic Therapy Outline for new information request form:

    Patient name/ID
    Prescribing MD/Address/Phone#
    Other MD's following patient for Lyme disease /PCP if different from prescribing MD
    Other ID information as needed

    LYME DISEASE STAGE/MANIFESTATION FOR WHICH IV THERAPY IS PRESCRIBED(CURRENT CLAIM OR PREAUTHORIZATION)

    HISTORY (include dates)
    initial exposure/manifestations
    prior treatment: list in chronologic order from first treatment to most recent. Include specific drug(s) used, duration, route of administration, treatment result and side effects

    CURRENT PHYSICAL FINDINGS: focus on objective findings that are manifestations of Lyme infection

    LABORATORY AND OTHER TEST FINDINGS: Including confirmatory Lyme serology, CSF analysis, EMG/NCV studies, electrocardiogram, neuropsychologic testing, imaging studies, as needed to establish that objective findings are the result of Lyme disease.

    CONSULTATION REPORTS, from any other physician(s) attending the case.

    TREATMENT PLAN: Drug, dose, frequency, route, duration, infusion provider, projected cost per service item (drug, ancillary supplies, professional services, etc)


    The Lyme Disease Network of NJ, Inc.
    43 Winton Road
    East Brunswick, NJ 08816
    http://www.lymenet.org/