Does Medicare Cover Lyme Disease Testing?
Does Medicare cover Lyme disease testing? Understand your coverage, navigate the process, and manage potential out-of-pocket costs.
Lyme disease is a bacterial infection transmitted through infected blacklegged ticks. It can cause symptoms like fever, headaches, fatigue, and a distinctive skin rash (erythema migrans). Untreated, it can affect joints, the heart, and the nervous system. Medicare, the federal health insurance program for those 65 or older and certain younger people with disabilities, covers medically necessary services, including diagnostic testing for Lyme disease.
Understanding Lyme Disease Testing
Diagnosing Lyme disease typically involves laboratory tests that detect antibodies to the Borrelia burgdorferi bacteria. The Centers for Disease Control and Prevention (CDC) recommends a two-step serologic testing process using FDA-cleared assays. This approach helps improve diagnostic accuracy, especially given that antibodies may take several weeks to develop after infection.
The initial screening test is often an Enzyme-Linked Immunosorbent Assay (ELISA), which identifies the presence of antibodies to the Lyme bacteria. If the ELISA result is negative, further testing is generally not recommended. However, if the ELISA test is positive or indeterminate, a second, more specific test is performed to confirm the results.
The confirmatory test commonly used is the Western blot, which detects antibodies (IgM and IgG) that react to specific proteins of the Lyme bacteria. A positive Western blot result helps confirm a Lyme disease diagnosis. Newer approaches, known as Modified Two-Tiered Testing (MTTT), may use a second immunoassay instead of a Western blot, which can improve sensitivity in earlier stages of the disease.
Medicare Coverage Specifics for Lyme Disease Testing
Medicare generally covers blood tests for Lyme disease when a physician or provider determines them to be medically necessary. Medical necessity means services or items are reasonable and essential for diagnosing or treating an illness or injury. This means the test must be ordered based on a patient’s symptoms, potential exposure to infected ticks, and the physician’s clinical judgment.
Lyme disease diagnostic laboratory tests are typically covered under Medicare Part B, which addresses outpatient medical services. For coverage, these tests must be performed by laboratories approved by Medicare. If a test is ordered without a diagnosis code that supports medical necessity, Medicare may deny payment.
Medicare Advantage Plans, also known as Medicare Part C, are offered by private companies approved by Medicare. These plans must cover at least everything that Original Medicare (Parts A and B) covers, including medically necessary Lyme disease testing. However, Medicare Advantage plans may have different networks of doctors and laboratories, as well as varying cost-sharing structures. Beneficiaries with these plans should verify their plan’s specific network requirements.
Navigating Coverage and Potential Costs
After receiving medical services, including Lyme disease testing, individuals with Medicare Advantage plans will typically receive an Explanation of Benefits (EOB) from their plan. An EOB is not a bill, but rather a summary detailing the services received, the amount billed, how much the plan covered, and any out-of-pocket costs due. It is advisable to review these documents for accuracy and contact the plan if any discrepancies are found.
For those with Original Medicare, out-of-pocket costs for Part B services, such as laboratory tests, include an annual deductible and coinsurance. In 2025, the standard Part B annual deductible is $257. After meeting this deductible, beneficiaries are generally responsible for 20% of the Medicare-approved amount for most Part B services, with Medicare covering the remaining 80%. There is no annual limit on out-of-pocket expenses with Original Medicare.
If a claim for Lyme disease testing is denied, beneficiaries have the right to appeal the decision. The appeal process typically involves several levels, starting with a redetermination by Medicare or the plan. Understanding the reason for denial, often stated on the EOB, is the initial step in preparing an appeal.
Before receiving services, it is important to confirm that the doctor and laboratory accept Medicare assignment. This ensures they agree to accept the Medicare-approved amount as full payment, limiting potential out-of-pocket expenses to deductibles and coinsurance. Medicare’s Care Compare tool or a direct inquiry to the provider’s office can help verify their Medicare participation status.