Harvard Pilgrim is updating our commercial prior authorization criteria for parenteral antibiotic treatment of Lyme and other tick-borne diseases, effective for dates of service beginning Feb. 22, 2018. Updates include adding 5 additional codes to the policy requiring prior authorization; changes to the limits on the number of days for which parenteral antibiotics are covered for human granulocytic anaplasmosis (HGA); and a coverage exclusion related to doses or courses of treatment far in excess of approved treatment regimens.
Harvard Pilgrim will continue to require prior authorization for all commercial members receiving parenteral (IV) antibiotic treatment of Lyme and other tick-borne diseases in outpatient, office, or home settings. Harvard Pilgrim considers parenteral antibiotics — such as ceftriaxone, cefotaxime, clindamycin, and penicillin — to be medically necessary for the treatment of Lyme disease for up to 30 consecutive days, when they are ordered by a licensed physician and documentation confirms all the criteria included in the policy.
The updated policy will now require prior authorization for the following additional codes for the treatment of Lyme disease:
- J0120 - Injection, tetracycline, up to 250 mg
- J0558 – Injection, penicillin G benzathine and penicillin G procaine, 100,000 units
- J0561 – Injection, penicillin G benzathine, 100,000 units
- J0697 – Injection, sterile cefuroxime sodium, per 750 mg
- J1364 – Injection, erythromycin lactobionate, per 500 mg
In addition, Harvard Pilgrim is changing the limit to the number of days for which parenteral doxycycline is considered reasonable and medically necessary for the treatment of HGA from 10 to 14 days.
Under the updated policy, Harvard Pilgrim will not provide coverage for doses of antimicrobials far in excess of approved doses or multiple, repeated courses of antimicrobials for the same episode of Lyme disease or a duration of antimicrobial therapy prolonged far in excess of approved regiments.
For complete information, refer to the updated Lyme/Tick-Borne Diseases: Use of Parenteral Antibiotics Medical Review Criteria.