Lyme Disease denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for either or both laboratory tests. Findings: Two of the three physician reviewers found that a portion of the services at issue was likely to be more beneficial for the evaluation of the patient’s medical condition than any available standard therapy. Patients with early disseminated Lyme disease often have constitutional symptoms related to bacteremia, including fever, headache, arthralgias, and malaise. Most patients with early Lyme disease can be cured with a short course of oral antibiotic therapy. One well-defined clinical subgroup of Lyme disease patients who experience ongoing symptoms following treatment is post-treatment Lyme disease (PTLD). The diagnosis is made clinically by documenting a prior history of Lyme disease and excluding other potential causes of persistent symptoms.

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for laboratory services. The patient resides in an endemic area for the pathogens tested. The patient’s history of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) is not a reason to avoid testing for other causes of fever such as tick-borne infections following a tick bite. Lyme serologies are the main test used to diagnose Lyme disease. The tests for Babesia, Ehrlichia, and Anaplasma in question are more likely to be positive during the acute phase of infection when compared to serological testing for those organisms. Peripheral blood smear review is also a standard test used to diagnose Babesia. The Centers for Disease Control (CDC) lists the tests in question as part of the evaluation of patients with suspicion of tick-borne infections.

Where the denial was upheld

Physician 1The patient is a 34-year-old female first diagnosed with Lyme disease in 2001. She subsequently received multiple courses of antibiotic with minimal long-term results. She had one six-month course of antibiotic with minimal change in her condition. She reports experiencing fatigue, paresthesia, arthralgias, fever, photophobia and headaches. These symptoms have persisted for several years. The patient feels the symptoms are increasing in severity. Physical exam findings include peripheral neuropathy with no effusions or erosion of large joints. Laboratory data include a positive IgG Western blot, normal brain MRI, and abnormal nerve conduction studies. No CSF analysis has been provided. A request has been made for continued intravenous antibiotic therapy.

Physician 1: The patient is a 65-year-old man who is said to have a history of Lyme disease. There is no evidence in the provided materials that the patient actually had this disease. The results of the definitive serological tests (Western Blots) included in the records are not conclusive. No other laboratory data of consequence is provided. There is a CD57 count that is slightly low and a non-specific SPECT brain scan performed in 2003; these are not diagnostic of Lyme disease.There is no mention in the submitted information of tick exposure or the characteristic rash seen in early Lyme disease. The medical records provided are from the patient’s primary care physician. The records note the patient is being treated with intravenous Rocephin and a quinolone antibiotic. He was given intravenous Rocephin for 10.5 months.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving lyme disease, then check the rights and deadlines that apply to your plan.