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Lyme disease A031

Last amended 
17 March 2016
Current RMA Instruments:
Reasonable Hypothesis SOP
25 of 2016
Balance of Probabilities SOP
26 of 2016
Changes from previous Instruments:

SOP Bulletin 188

ICD Coding:
  • ICD-9-CM Codes: 088.81
  • ICD-10-AM Codes: A69.2
Brief description

Lyme disease is a clinical illness caused by a bacterial infection acquired from a tick bite.  The infection is with one of a group of specific spirochete bacteria from the Borrelia genus.  It has a characteristic rash (not always present).  Clinical manifestations vary and there can be early and late stages of infection.  The early stage may have nonspecific signs and symptoms (apart from the rash) resembling a viral syndrome.  The late stage of infection typically includes an arthritis in one or more large joints.  

Confirming the diagnosis

The diagnosis needs to be confirmed by laboratory testing in the manner specified in the SOP.  This condition can only be acquired from being in temperate areas in north America, Europe or Asia (as specified in the SOP).  The organisms and ticks that cause this condition have not been confirmed to be present in Australia.  The disease covered by this SOP cannot be acquired in Australia (see further comments on diagnosis, below).

The relevant medical specialist is an infectious diseases physician. 

Additional diagnoses covered by SOP
  • Nil
Conditions not covered by SOP
  • Australian-acquired "Lyme disease"#
  • "Lyme-like" disease#
  • "Post-Lyme disease syndrome"#
  • "Chronic Lyme disease"#

# non-SOP condition - see further comments below

Further comments on diagnosis
  • The SOP covers only the classic form of internationally-acquired Lyme disease.

  • Neither “Lyme-like disease” nor Australian acquired “Lyme disease” is covered by a SOP. There is no established way to confirm such a diagnosis and any claims received for such a condition will present difficulties as to whether there is a particular disease or injury present for the purposes of the VEA or the MRCA.

  • "Post-Lyme disease syndrome" describes the nonspecific symptoms (such as headache, fatigue, and arthralgias) that may persist for months after treatment of Lyme disease.  This is a non-SOP condition.  The evidence in the particular case should be considered to determine whether a dsiease or injury is present and whether it is related to prior (confirmed) Borrelia species infection.

  • "Chronic Lyme disease" is a label typically used to describe illnesses and symptom complexes for which there is no convincing scientific evidence of any relationship to infection with Borrelia species.  A claim for Chronic Lyme disease, when the term is used in this way, should be regarded as no incapacity found.  Alternative diagnosis should be considered.

Clinical onset

If the characteristic rash (erythema migrans) develops, the clinical onset will be at the time the rash appears.  Some patients present in a later stage of Lyme disease without a history of prior signs or symptoms suggestive of earlier Lyme disease.  In such cases onset may be an extended time (from months up to a few years) after being in an endemic area. 

Clinical worsening

The only SOP worsening factor is for inability to obtain appropriate clinical management.  The condition is responsive to appropriate antibiotic therapy.