Lyme Disease Association, Inc. - Blue Cross Press Release and Lyme Disease Diagnosis and Treatment Act

Full text of Blue Cross Press Release and Lyme Disease Diagnosis and Treatment Act follow this agreement.

August 22, 2002

Presently, Blue Cross covers up to four weeks of intravenous antibiotic therapy deemed medically necessary by a treating physician for certain illnesses including Lyme disease.

Blue Cross agrees with and will adopt the following statement of its policy in its physician’s manual regarding testing and treatment of Lyme disease to become effective by July 1:

1) Lyme disease means the official diagnosis by a physician of the presence in a patient of signs and symptoms compatible with acute infection with Borrelia burgdorferi, or with late stage infection with Borrelia burgdorferi, or with complications related to such an infection. “Lyme disease” includes infection which meets the surveillance criteria set forth by the U.S. Centers for Disease Control and Prevention (CDC), but also includes other acute and late stage manifestations of such an infection as determined by the physician.

2) Blue Cross will cover long term antibiotic therapy (meaning administration of oral, intramuscular or intravenous antibiotics, single or in combination, for periods greater than four weeks) to control Lyme disease and its sequelae, when a physician, acting in accordance with the Lyme Disease Diagnosis and Treatment Act (R.I. Gen. Laws§ 5-37.5 et. seq.), orders such therapy after making a thorough evaluation of the patient’s symptoms, diagnostic test results, response to treatment, and physician-documented objective clinical change.

3) If Blue Cross disagrees with the order of the physician, it will immediately process the appeal in accordance with the Health Care Services—Utilization Review Act on an expedited basis, including forwarding the appeal to an unrelated and objective independent third party entity designated by the Director of the Rhode Island Department of Health (“DOH”). It shall be up to the individual requesting the external appeal to select the unrelated and objective entity from those designated by the Director. All reviews will be at the expense of Blue Cross. The review agency shall consider all evidence submitted by the patient’s treating physician(s). The review agency will make determinations regarding coverage based upon medical necessity/appropriateness based upon that particular individual’s clinical status.

4) Neither Blue Cross, nor the independent reviewer, shall contest, reverse, or deny coverage based upon a physician’s order of long term antibiotic therapy solely on the ground that such treatment may be characterized as unproven, experimental, or investigational in nature.

5) During the pendency of the review, the prescribed treatment shall be covered by Blue Cross.

6) The decision of the independent review agency shall be binding, but subject to reconsideration at the request of a treating physician based upon a change in clinical condition or analysis or diagnostic testing.

James E. Purcell
Chief Operating Officer and Executive Vice President BC/BS of RI

CHAPTER 159
2002-H 7996A
Enacted 06/25/2002

A N A C T RELATING TO LYME DISEASE TREATMENT

Introduced By: Representatives Rabideau, and Ginaitt

Date Introduced: April 04, 2002

It is enacted by the General Assembly as follows:

SECTION 1. Title 5 of the General Laws entitled "Businesses and Professions" is hereby amended by adding thereto the following chapter:

CHAPTER 37.5
LYME DISEASE DIAGNOSIS AND TREATMENT

5-37.5-1. Title. -- This chapter shall be known and may be cited as the "Lyme Disease Diagnosis and Treatment Act."

5-37.5-2. Preamble.

WHEREAS, The Governor's Commission on Lyme Disease and Other Tick-Borne Diseases (the "Commission") was formed by executive order in 2002; and

WHEREAS, The General Assembly recognizes the negative impact of Lyme disease on Rhode Islanders; and

WHEREAS, Rhode Island has the second highest number of reported Lyme disease cases as a percentage of population in the United States; and

WHEREAS, The Commission and the General Assembly held hearings and reviewed the medical literature to gain an understanding of the concerns of citizens and the medical community about Lyme disease diagnosis, treatment and prevention; and

WHEREAS, Citizens of Rhode Island diagnosed with chronic lyme disease experience great difficulty in being diagnosed and treated thereby impairing their access to medical care; and

WHEREAS, The lack of insurance coverage for diagnosis and long-term antibiotic therapies is a major barrier to access to medical care for person with symptoms compatible with chronic Lyme disease; and

WHEREAS, Physicians whose practices are devoted to treating chronic Lyme disease patients, and who continue to provide treatment if they feel such treatment is medically necessary, have noted significant improvement in the condition of their patients; and

WHEREAS, There is substantial evidence that considerable scientific controversy surrounds the diagnosis and treatment of Lyme disease and other tick-borne illnesses; and

WHEREAS, Laboratory tests for Lyme disease are not definitive and consensus guidelines for diagnosis and treatment of chronic Lyme disease have not been developed; and

WHEREAS, Some physicians feel threatened by insurers and licensing boards for their choices among possible therapies for their patients; and

WHEREAS, The Commission and this General Assembly recommend that legislation be adopted that promotes access to medical care for persons with chronic Lyme disease in Rhode Island; and

Now, therefore, it is enacted by the General Assembly as follows:

5-37.5-3. Definitions.-- -- For purposes of the chapter:

(1) "Board" means the Rhode Island Board of Medical Licensure and Discipline;

(2) "Lyme disease" means the clinical diagnosis by a physician of the presence in a patient of signs and symptoms compatible with acute infection with Borrelia burgdorferi, or with late stage or chronic infection with Borrelia burgdorferi, or with complications related to such an infection. "Lyme disease" includes infection which meets the surveillance criteria set forth by the US Centers for Disease Control and Prevention (CDC), but also includes other acute and chronic manifestations of such an infection as determined by the physician;

(3) "Physician" means persons licensed pursuant to chapter 5-37 by the board;

(4) "Therapeutic purpose" means the use of antibiotics to control a patient's symptoms determined by the physician as reasonably related to Lyme disease and its sequelae.

(5) "Long term antibiotic therapy" means administration of oral, intramuscular or intravenous antibiotics, singly or in combination, for periods of greater than four (4) weeks.

5-37.5-2. Long Term Antibiotic Treatment. --(a) A physician may prescribe, administer, or dispense antibiotic therapy for therapeutic purpose to a person diagnosed with and having symptoms of Lyme disease if this diagnosis and treatment plan has been documented in the physician's medical record for that patient. No physician is subject to disciplinary action by the board solely for prescribing, administering or dispensing long-term antibiotic therapy for a therapeutic purpose for a patient clinically diagnosed with Lyme disease, if this diagnosis and treatment plan has been documented in the physician's medical record for that patient.

(b) Nothing in this section denies the right of the board to deny, revoke, or suspend the license of any physician or discipline any physician who prescribes, administers, or dispenses long-term antibiotic therapy for a non-therapeutic purpose, or who fails to monitor the ongoing care of a patient receiving long-term antibiotic therapy, or who fails to keep complete and accurate ongoing records of the diagnosis and treatment of a patient receiving long-term antibiotic therapy.

SECTION 2. This act shall be effective on July 1, 2002.