Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Immunizations

Policy #:08.01.04t

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

Refer to the following News Article:
Zoster and Hepatitis B Vaccines Approved by the US Food and Drug Administration and Advisory Committee on Immunization Practices (Revised 05/30/2018)

ROUTINE VACCINES

MEDICALLY NECESSARY
Routine vaccines for the indications described below are considered medically necessary and, therefore, covered in accordance with the Advisory Committee for Immunization Practices (ACIP) recommendations.

DTaP/Tdap/Td Vaccines

The following vaccines against diphtheria, tetanus, and pertussis are considered medically necessary and, therefore, covered for nonimmune individuals at risk for diphtheria, tetanus, and pertussis:
  • Routine childhood diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccination regimen at ages 2 months, 4 months, 6 months, 15 months through 18 months, and 4 years through 6 years. A fourth dose given as early as age 12 months will be covered if at least 4 months have elapsed since the third dose.
  • Catch-up DTaP vaccination for under-vaccinated children under 7 years of age at subsequent visits.
  • Routine dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) for all adolescents aged 11 through 12 years.
  • Catch-up one-time dose of Tdap for under-vaccinated (i.e., missing DTaP doses) children ages 7 years through 10 years followed by a dose at age 11-12 years.
  • Catch-up one-time dose of Tdap for adolescents ages 11 years through 18 years who have not received Tdap vaccine. This should be followed by tetanus and diphtheria (Td) booster doses every 10 years thereafter.
  • One-time dose of Tdap followed by one dose of Td every 10 years for adults ages 19 years and older who have not received tetanus and diphtheria toxoid containing vaccine, who lack evidence of immunity, or whose vaccine status is unknown.
  • One dose of Tdap to pregnant women during EACH pregnancy (preferred during 27-36 weeks gestation), regardless of the amount of time since prior Td or Tdap vaccination.
  • A Tdap booster vaccination for adolescents and adults any age (e.g., parents, siblings, grandparents) who previously have not received Tdap or whom pertussis vaccination status is unknown and who have, or anticipate having, close contact with an infant less than 12 months of age.
  • A Td booster vaccination once every 10 years for adults 19 years or older.

Haemophilus Influenzae Type b (Hib) Vaccine

Haemophilus influenzae type b (Hib) vaccine is considered medically necessary and, therefore, covered for the following individuals:
  • Routine childhood primary Hib vaccination series at ages 2 months, 4 months, and 6 months, and an Hib booster dose at ages 12 months through 15 months. (PRP-OMP is not indicated for the 6 month dose, only the doses at 2 months and 4 months.)
  • Catch-up Hib vaccination for under-vaccinated children up to 5 years of age at subsequent visits.
  • Hib vaccination for children with specific health conditions (e.g., anatomic or functional asplenia [including sickle cell disease], hematopoietic stem cell transplantation, human immunodeficiency virus (HIV), immunoglobulin deficiency, early component complement deficiency, elective splenectomy, chemotherapy treatment, or radiation treatment).
  • A 3-dose regimen 6-12 months after a successful hematopoietic stem cell transplant regardless of prior Hib vaccination history; at least 4 weeks should separate doses.
  • One dose of Hib vaccine to individuals who have functional or anatomic asplenia or sickle cell disease or are undergoing elective splenectomy if they have not previously received Hib vaccine. Hib vaccination 14 or more days before splenectomy is suggested.

Hepatitis A Vaccine

Hepatitis A virus (HAV) vaccine is considered medically necessary and, therefore, covered for the following individuals:
  • Routine two-dose regimen of hepatitis A (HepA) childhood vaccination. The first dose of HepA vaccine between 12 months and 23 months of age. Second (final) dose of HepA vaccine 6 to 18 months after the first.
  • Catch-up HepA vaccination for under-vaccinated children and adolescents up to 18 years of age at subsequent visits.
  • HAV vaccination for nonimmune individuals at risk for HAV infection (e.g., individuals with chronic liver disease, men who have sex with men, individuals with clotting-factor disorders, or users of injection or noninjection illicit drugs).
  • Unvaccinated persons who anticipate close personal contact (household or baby sitting) with an international adoptee during the first 60 days of their arrival from a country with high or intermediate endemicity
  • Adults seeking protection from Hepatitis A.
  • Healthy adults who have recently been exposed to hepatitis A virus.
  • HAV vaccination for individuals traveling to countries with high or intermediate endemicity

Hepatitis B Vaccine

Hepatitis B virus (HBV) vaccine is considered medically necessary and, therefore, covered for the following individuals:
  • Routine childhood HBV vaccination within 24 hours of birth, ages 1 month through 2 months, and 6 months through 18 months. Monovalent HepB vaccine for doses before age 6 weeks.
  • Catch-up HBV vaccination for un-vaccinated children and adolescents through 18 years at subsequent visits.
  • Routine HBV vaccination for individuals, ages 19 years through 59 years with diabetes mellitus or individuals diagnosed with diabetes who are over 60 years of age, at the discretion based on the likelihood of acquiring HBV.
  • Nonimmune individuals at risk for HBV infection, including, but not limited to:
    • Sexually active individuals who are not in a long-term mutually monogamous relationship
    • Individuals seeking evaluation or treatment for a sexually transmitted disease
    • Current or recent injection drug users
    • Men who have sex with men
    • Individuals with end-stage renal disease including those who are receiving predialysis care, hemodialysis, or peritoneal dialysis
    • Individuals with HIV infection
    • Individuals with chronic liver disease (e.g., hepatitis C infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice the upper limit of normal)
    • Household contacts and sex partners of hepatitis B surface antigen--positive individuals.
    • Pregnant individuals at risk for hepatitis B virus infection during pregnancy
    • Individuals receiving care in settings where a high proportion of adults have risks for hepatitis B infection.
  • Nonimmune individuals requesting protection from HBV infection.
  • Medically stable infants at least 2,000 grams whose mothers are HBsAg-negative are covered for one dose of monovalent HepB vaccine within 24 hours of birth. Infants less than 2,000 grams whose mothers are HBsAg-negative are covered for one dose of monovalent HepB vaccine at chronological age one month or hospital discharge.
  • Infants whose mother is HBsAg-positive regardless of birth weight are covered for one dose of monovalent HepB vaccine within 12 hours of birth.
  • Infants whose mother's HBsAg status is unknown regardless of birth weight are covered for one dose of monovalent HepB vaccine within 12 hours of birth.
  • Individuals traveling to countries with high or intermediate incidence of hepatitis B.

Human Papillomavirus Vaccine

9-valent papillomavirus vaccine (9vHPV) is considered medically necessary and, therefore, covered for the following individuals:
  • Routine two-dose regimen of 9vHPV for individuals 11 years or 12 years of age administered 6-12 months. The vaccination series is covered beginning at 9 years.
  • Individuals who begin the vaccination series at age 15 years through 26 years are covered for the three dose regimen of 9vHPV vaccine.
  • Catch-up vaccination for females age 13 years through 26 years who have not been vaccinated previously, who have not completed the three-dose series, or with primary or secondary immunocompromising conditions that might reduce immunity. If a female reaches age 26 years before the vaccination series is complete, remaining doses will be covered after age 26 years.
  • Catch-up vaccination for males 13 years through 26 years of age who have not been vaccinated previously, who have not completed the three-dose series, or with primary or secondary immunocompromising conditions that might reduce immunity.
  • HPV vaccines are not recommended for use in pregnant women.

Influenza Vaccine

Influenza vaccine is considered medically necessary and, therefore, covered for the following individuals:
  • Two-dose regimen for individuals age 6 months through 8 years receiving their first-time influenza vaccination or who have not previously received two or more doses of trivalent or quadrivalent vaccine before July 1, 2017.
  • Annual influenza vaccination with inactivated influenza vaccine (IIV) for individuals from age 6 months and older. Annual influenza vaccination with recombinant influenza vaccine, inactivated influenza vaccine (IIV), or live attenuated influenza vaccine (LAIV) for individuals 18 years or older.
  • Annual influenza vaccination with a standard-dose IIV for adults age 65 years and older or, alternatively, a high-dose of IIV.

Measles, Mumps, Rubella, and Varicella Vaccines

Measles, mumps, rubella vaccine (MMR) and varicella vaccine or combination measles, mumps, rubella, and varicella vaccine (MMRV) is considered medically necessary and, therefore, covered for the following individuals:
  • Routine childhood vaccination against measles, mumps, rubella, and varicella at ages 12 months through 15 months, and at ages 4 years through 6 years prior to entering school. The second dose may be covered before 4 years of age.
  • Catch-up measles, mumps, rubella, and varicella vaccination for under-vaccinated or unvaccinated children and adolescents up to 18 years of age at subsequent visits.
  • One dose of mumps-virus containing vaccine for individuals at least 12 months old who previously received a mumps-containing vaccine who are identified by the public health authorities to be at increased risk during a mumps outbreak.
  • A two-dose regimen of MMR vaccination for nonimmune adults at risk for measles and mumps infection (e.g., students in post-secondary educational institutions and household contacts of immunocompromised individuals).
  • One dose of MMR vaccination for individuals who lack evidence of measles, mumps, or rubella immunity.
  • A two-dose regimen of single-antigen varicella vaccination for unvaccinated adults who lack evidence of varicella immunity.
  • A second dose of single-antigen varicella vaccination for nonimmune adults with incomplete varicella vaccination.
  • MMR vaccine and varicella vaccine are covered for females of childbearing age and pregnant females with no evidence of immunity.
  • MMR vaccination before departure for international travel.

Meningococcal Conjugate and Meningococcal Polysaccharide Vaccines

Meningococcal conjugate vaccine (MenACWY-D, MenACWY-CRM) or meningococcal polysaccharide vaccine (MPSV4) is considered medically necessary and, therefore, covered for the following individuals:
  • Routine one-dose regimen of meningococcal vaccination (MenACWY-D or MenACWY-CRM) for adolescents age 11 years or 12 years, with a one-time booster dose at age 16 years.
  • A catch-up dose of MenACWY-D or MenACWY-CRM vaccine at age 13 through 18 years if not previously vaccinated
  • For individuals aged 2 months or older with high risk conditions or at increased risk of disease (i.e., anatomic or functional asplenia [including sickle cells disease], HIV infection, persistent complement component deficiency [individuals with inherited or chronic deficiency in C3, C5-9, properidin, factor D, factor H, or taking eculizumab [Soliris®]) with MenACWY-D, or MenACWY-CRM.
  • For adults with increased risk for meningococcal disease who are aged 55 years or younger as well as for adults 56 years or older who were vaccinated previously with MenACWY-D or MenACWY-CRM and are recommended for vaccination or whom multiple doses are anticipated. Meningococcal polysaccharide vaccine (MPS4) is preferred for adults aged 56 years or older who have not received MenACWY-D or MenACWY-CRM previously and who require a single dose only.
  • For adults at risk of a meningococcal disease outbreak attributed to serogroup A,C, W, or Y.
  • First-year college students who are living in residence halls are covered if they have not received a dose on or after their 16th birthday.
  • Revaccination with MenACWY-D or MenACWY-CRM every 5 years is covered for adults previously vaccinated with MenACWY-D or MenACWY-CRM or MPSV4 who remain at increased risk for infection (e.g., adults with anatomic or functional asplenia, persistent complement component deficiencies).
  • Individuals who travel to countries where meningococcal dissease is hyperendemic or epidemic, including countries in the African meningitis belt or during the Hajj.

Serogroup B meningococcal (MenB) vaccine is considered medically necessary and, therefore, covered for the following:
  • Two-dose series to individuals 10 years or older who are not at increased risk for meningococcal disease
  • Two-dose series or three dose series to individuals 10 years or older who are at increased risk for meningococcal disease with any of the following:
    • Persistent complement component deficiencies (including inherited or chronic deficiencies in C3, C5-9, properdin, factor D, factor H, or who are taking eculizumab [Soliris®])
    • Anatomic or functional asplenia including sickle cell disease
    • Identified at increased risk because of a serogroup B meningococcal disease outbreak
  • Individuals 16 through 23 years are covered when vaccinated with a 2 dose series or a 3 dose series to provide short-term protection against most strains of serogroup B meningococcal disease. The same product must be used for all doses.

Pneumococcal Vaccine

13-valent pneumococcal polysaccharide-protein conjugate vaccine (PCV13) or 23-valent pneumococcal polysaccharide vaccine (PPSV23) is considered medically necessary and, therefore, covered for the following individuals:

Children
  • Routine childhood PCV13 vaccination at ages 2 months, 4 months, 6 months, and 12 months through 15 months. The first dose of PCV13 is covered as early as 6 weeks of age.
  • Catch-up PCV13 vaccination for under-vaccinated healthy children up to 5 years of age at subsequent visits.
  • Vaccination of persons with high-risk conditions with PCV13 and PPSV23:
    • For children 2 years through 18 years of age with any of the following conditions: chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including asthma if treated with high-dose corticosteroid therapy); diabetes mellitus; cerebrospinal fluid leak; cochlear implant; sickle cell disease and other hemoglobinopathies; anatomic or functional asplenia; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas, and Hodgkin disease; solid organ transplantation; acquired or congenital immunodeficiency; multiple myeloma.
    • For children aged 6 through 18 years with alcoholism, or chronic liver disease.

Adults 19 years and older
  • Adults aged 19 or older with immunodeficiency disorders, HIV infection, anatomical or functional asplenia, chronic renal failure and nephrotic syndrome, cerebrospinal fluid leak, or cochlear implant.
  • Adults aged 19 years through 64 years with chronic heart disease (including congestive heart failure and cardiomyopathies, excluding hypertension), chronic lung disease (including chronic obstructive lung disease, emphysema, and asthma), chronic liver disease (including cirrhosis), alcoholism, diabetes mellitus, or smoke cigarettes.
  • PCV13 and PPSV23, when indicated, will be covered for individuals whose pneumococcal vaccination history is incomplete or unknown.
  • Adults 65 years of age or older who have not received PCV13 but have received a dose of PPSV23 at age 65 years or older.
  • Adults 65 years of age or older who have received PCV13 but not PPSV23 before 65 years of age.
  • Adults 65 years of age or older who have received PCV13 and 1 or more doses of PPSV23 before the age of 65.

Polio Vaccine

Inactivated poliovirus vaccine (IPV) is considered medically necessary and, therefore, covered for the following individuals:
  • Routine childhood polio vaccination at ages 2 months, 4 months, 6 months through 18 months, and 4 years through 6 years.
  • Catch-up polio vaccination for under-vaccinated children and adolescents up to 18 years at subsequent visits.
  • Polio vaccination for certain high-risk groups (e.g., unvaccinated adults with children receiving oral poliovirus vaccine [OPV] or members of specific populations at risk for wild poliovirus infections).

Rotavirus Vaccine

Rotavirus vaccines (RV5 [RotaTeq] or RV1 [Rotarix]) are considered medically necessary and, therefore, covered for the following individuals:
  • An oral three-dose live, human-bovine pentavalent rotavirus vaccination (RV5) regimen at ages 2 months, 4 months, and 6 months.
  • An oral two-dose live, human-attenuated rotavirus vaccination (RV1) regimen at ages 2 months and 4 months.
  • A total of up to three doses of rotavirus vaccines if prior vaccination included use of Rotateq (RV5) or unknown rotavirus vaccines.
  • Catch-up rotavirus vaccination up to 8 months of age.

Zoster (Shingles) Vaccine

Zoster (shingles) vaccine is considered medically necessary and, therefore, covered for the following individuals:
  • Zoster vaccine live for individuals age 60 years or older, regardless of whether they experienced a prior episode of herpes zoster.
  • Recombinant zoster vaccine for immunocompetent individuals age 50 years or older, regardless of whether they experienced a prior episode of herpes zoster or received zoster vaccine live.
  • Zoster vaccine live for individuals aged 60 years or older with chronic medical conditions will be covered unless their condition constitutes a contraindication, such as pregnancy or severe immunodeficiency.
  • Recombinant zoster vaccine for immunocompetent individuals aged 50 years or older with chronic medical conditions will be covered unless their condition constitutes a contraindication.

EXPERIMENTAL/INVESTIGATIONAL
The following vaccines are considered experimental/investigational and, therefore, not covered as the ACIP has not issued a recommendation:
  • Influenza virus vaccine, split virus, preservative free, for intradermal use
  • Influenza virus vaccine, pandemic formulation, live, for intranasal use
  • Influenza virus vaccine, pandemic formulation, split virus, preservative free, for intramuscular use
  • Influenza virus vaccine, pandemic formulation, split virus, adjuvanted, for intramuscular use
  • Influenza virus vaccine, pandemic formulation, split virus, for intramuscular use
  • Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Hemophilus influenza type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-HibHepB)

Rotavirus Vaccine

Rotavirus vaccines (RV5 [RotaTeq] or RV1 [Rotarix]) are considered experimental/investigational when any of the following criteria are met:
  • Individual is older than one years of age
  • The number of doses has exceeded 3

Zoster (Shingles) Vaccine

Zoster (shingles) vaccine is considered experimental/investigational for individuals under 50 years.

Human Papillomavirus Vaccine

Bivalent human papillomavirus vaccine (2vHPV), quadrivalent human papillomavirus vaccine (4vHPV) or 9-valent papillomavirus vaccine (9vHPV) is considered experimental/investigational for individuals younger than 9 years and individuals older than 27 years.

NOT ELIGIBLE FOR REIMBURSEMENT
The following vaccines are no longer manufactured and have been withdrawn from the market, therefore, they are not eligible for reimbursement:
  • Hepatitis A vaccine, 3-dose schedule intramuscular
  • Influenza virus vaccine, trivalent vaccine, intranasal

NON-ROUTINE VACCINES

MEDICALLY NECESSARY
Non-routine vaccines for the indications described below are considered medically necessary and, therefore, covered in accordance with Advisory Committee for Immunization Practices (ACIP) recommendations.

Tdap/Td Vaccines

Tdap or Td vaccine (tetanus toxoid-containing vaccine) is considered medically necessary and, therefore, covered for tetanus wound management for the following individuals:
  • For individuals with a history of three or more doses of absorbed tetanus toxoid vaccination:
    • Td vaccine (Tdap may be substituted for Td in individuals older than 10 years who have previously not received Tdap, or in individuals 7-10 years of age who are under-vaccinated against pertussis).
      • A booster dose of tetanus toxoid-containing vaccine if it has been more than 10 years since the last tetanus toxoid dose and the wound is clean and minor.
      • A booster dose of tetanus toxoid-containing vaccine if it has been more than 5 years since the last tetanus toxoid dose and the wound is other than clean and minor.
  • For individuals with an unknown history or a history of less than three doses of absorbed tetanus toxoid vaccination:
    • Td vaccine (Tdap may be substituted for Td in individuals older than 10 years who have previously not received Tdap, or in individuals 7-10 years of age who are under-vaccinated against pertussis).

Post-Exposure Rabies Vaccine

Post-exposure rabies vaccine, for intramuscular use, is considered medically necessary and, therefore, covered for the following individuals:
  • A four-dose regimen in combination with rabies immune globulin (RIG) for healthy individuals as treatment of an injury or direct exposure to rabies disease or condition.
  • A five-dose regimen with one dose of RIG for individuals with altered immunocompetence.

BCG Vaccine

Bacille Calmette-Guerin (BCG) vaccine is considered medically necessary and, therefore, covered for individuals when either of the following criteria are met:
  • For children who have a negative tuberculin skin test and who are continually exposed to, and cannot be separated from, adults who are untreated or ineffectively treated for tuberculosis (TB) disease (if the child cannot be given long-term treatment for infection).
  • For children who have a negative tuberculin skin test and who are continually exposed to, and cannot be separated from, adults who have TB caused by strains resistant to isoniazid and rifampin.

Typhoid Vaccine

Typhoid vaccine is considered medically necessary and, therefore, covered for individuals with intimate exposure (e.g., household contact) to a documented Salmonella serotype Typhi chronic carrier (defined as excretion of Salmonella serotype Typhi in urine or stool for more than one year).

Zoster (Shingles) Vaccine

Zoster (shingles) vaccine live is medically necessary and, therefore, covered for individuals between the ages of 50-59 years.

EXPERIMENTAL/INVESTIGATIONAL
Rabies Vaccine

The rabies vaccine for intradermal use is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

Dengue Vaccine
The dengue vaccine is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

NOT MEDICALLY NECESSARY
The following non-routine vaccines are considered not medically necessary and, therefore, not covered, as the ACIP has not issued a recommendation for their use:
  • Pre-exposure rabies vaccine
  • Pre-event anthrax vaccine

NOT ELIGIBLE FOR REIMBURSEMENT
The following vaccines are no longer manufactured and have been withdrawn from the market, therefore, they are not eligible for reimbursement:
  • Oral poliovirus vaccine (OPV)
  • Plague vaccine

TRAVEL-RELATED VACCINES

The following vaccines used exclusively for traveling purposes are not covered by the Company because they are a benefit contract exclusion. Therefore, they are not eligible for reimbursement consideration.
  • Japanese encephalitis (JE)
  • Typhoid
  • Yellow fever (has country-specific requirements)
  • Cholera

There are additional vaccines, both routine and non-routine that are commonly, but not exclusively, used for travel purposes. When routine vaccines are used solely for travel-related purposes in accordance with the ACIP recommendations, the routine vaccines are considered medically necessary and, therefore, covered by the Company.

EMPLOYMENT/OCCUPATION-RELATED VACCINES

Vaccines used prophylactically for employment purposes, occupational requirements, or work-related injuries are not covered by the Company because they are a benefit contract exclusion. Therefore, they are not eligible for reimbursement consideration.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the professional providers' office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the
participation status of the provider. All documentation must be made available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

Medical necessity criteria for preventive immunization are subject to change based on updated recommendations of the Center for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) as published in Morbidity and Mortality Weekly Report (MMWR).

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, vaccines are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

MANDATES

This policy is consistent with applicable state and federal mandates. The laws of the state where the benefit contract is issued determine the mandated coverage, in addition to any applicable federal mandates.

BILLING GUIDELINES

ACIP has no additional recommendations for the usage of US Food and Drug Administration (FDA)--approved multiantigen combination vaccines over single-antigen vaccines or vice versa.

Vaccination is reimbursed per vaccine agent given as opposed to per vaccine injection administered. Multiple-antigen vaccine (e.g., MMRV [measles, mumps, rubella, varicella]) administered in one injection will receive equal amount of reimbursement as if the same components of the vaccine were to be injected separately.

PREVENTIVE VACCINE SERVICES

For members who have zero cost-share preventive services in accordance with the Patient Protection and Affordable Care Act (PPACA) of 2010 and the Health Care and Education Reconciliation Act (HCERA) of 2010, no cost-share (i.e., copayments, deductibles, coinsurance) will be applied to routine preventive vaccines (vaccine and administration) that are recommended by the Advisory Committee on Immunization Practices (ACIP).

According to the CDC bivalent human papillomavirus (2vHPV) vaccine expired in November 2016. The last dose of quadrivalent human papillomavirus (4vHPV) vaccine expired in May 2017. 2vHPV and 4vHPV will be considered preventive for individuals 9-26 years of age until May 2018.

Based on ACIP recommendations, all healthy children who may have received 7-valent pneumococcal conjugate vaccine (PCV7) as part of a primary series have aged out of the recommendation for pneumococcal vaccine. PCV7 is no longer recommended as part of the routine immunization schedule. PCV7 will continue to be considered preventive to allow for claims run out.

Description

Vaccination is a deliberate attempt to protect humans against infectious disease by both preventing disease in immunized individuals and by creating barriers to the spread of infectious disease. Preventable, once-threatening diseases that are now controlled by vaccines include polio, measles, diphtheria, pertussis, rubella, mumps, and tetanus.

Humans are born with some natural defense mechanisms against bacteria, viruses, and other infectious organisms: this is referred to as innate, nonspecific immunity and includes barrier methods such as the skin, antibodies received from the mother during gestation (passive immunity), and antibodies that develop in the neonate at 2 to 3 months of age. Acquired immunity is developed in response to infection or vaccination and is specific to the invading organism. Immunity induced by infection or vaccination is called active immunity. Immunity is established when memory cells develop and then detect invading organisms and defend against the original antigen during re-infection.

Actual vaccines contain weakened or killed antigens and are injected into fatty tissue or muscle. Without causing disease, these antigens prompt the immune system to produce antibodies against vaccine-preventable diseases. However, in some cases, as with the rabies vaccine, the vaccine is administered to provide post-exposure prophylaxis against infection.

ROUTINE VACCINES

Routine vaccines are vaccines that are included on the recommended immunization schedule published by the Advisory Committee on Immunization Practices (ACIP). The recommended immunization schedule is to be followed throughout an individual's lifespan. Vaccines given after the recommended immunization scheduled time are called catch-up immunizations. A catch-up regimen allows for the administration of the remaining doses of the vaccination to ensure that the individual continues to receive timely coverage against vaccine-preventable disease.

DIPHTHERIA, TETANUS, AND PERTUSSIS (DTAP)/TETANUS, DIPHTHERIA AND PERTUSSIS (TDAP)/ TETANUS, DIPHTHERIA (TD) VACCINES
Diphtheria, tetanus, and pertussis are serious diseases preventable by vaccination. Diphtheria can lead to respiratory difficulty, paralysis, heart failure, and even death. Tetanus causes painful muscle tightening and convulsive spasms of the skeletal muscle and fatal in about 1% of cases. Pertussis (whooping cough) can lead to pneumonia, seizures, brain damage, and death.

HAEMOPHILUS INFLUENZAE TYPE B VACCINE
Haemophilus influenzae type B (HiB) vaccine provides protection against Haemophilus influenzae type b, which primarily infects children under 5 years of age. Hib can cause meningitis and can lead to complications such as lasting brain damage, blindness, deafness, and death. Other complications of Hib include pneumonia, epiglottitis, and serious infections of blood, bones, joints, and the covering of the heart. Healthy children over 5 years of age usually do not need Hib vaccine.

HEPATITIS A VACCINE
Hepatitis A vaccine provides protection against hepatitis A virus (HAV), which causes an acute liver disease, lasting from a few weeks to several months. HAV does not lead to chronic infection. HAV is transmitted via ingestion of fecal matter, either from close person-to-person contact or from ingestion of contaminated food or drinks.

HEPATITIS B VACCINE
The hepatitis B vaccine provides protection against hepatitis B virus (HBV), which is a blood borne and sexually transmitted virus. The complications of hepatitis B can lead to cirrhosis, liver cancer, liver failure, and death.

HUMAN PAPILLOMAVIRUS VACCINE
Human papillomavirus vaccine provides protection against genital human papillomavirus (HPV), which is the most common sexually transmitted infection in the United States. There are more than 40 HPV types that can infect the genital areas of males and females. Rarely, these HPV types can also infect the mouth and throat. Although the majority of infections are asymptomatic and self-limited, persistent infection with oncogenic types can lead to cervical cancer. HPV infection can also cause genital warts and is associated with other anogenital cancers. There is one type of vaccine currently available, a 9-valent HPV vaccine (9vHPV). 9vHPV protects against HPV types 6,11,16,18, 31, 33, 45, 52, and 58. In November 2016, the last dose of the bivalent HPV vaccine expired. In May of 2017 the last doses of the quadrivalent HPV vaccine expired.

INFLUENZA VACCINE
Influenza vaccine provides protection against influenza viruses that infect the nose, throat, and lungs and cause contagious respiratory illness. Influenza viruses can cause mild to severe illness, and at times can lead to death. There are two main types of influenza (flu) virus: types A and B. The influenza A and B viruses that routinely spread in people (human influenza viruses) are responsible for seasonal flu epidemics each year. Influenza A viruses can be broken down into sub-types depending on the genes comprising the surface proteins. Over the course of a flu season, different types (A and B) and subtypes (influenza A) of influenza circulate and cause illness. Influenza viruses are always changing, so annual vaccination is recommended by the Centers for Disease Control and Prevention (CDC). Scientists try to match the viruses in the vaccine to those most likely to cause flu that year. There are two types of influenza vaccine, also called inactivated (killed) influenza vaccine (IIV), given by injection with a needle or by a live, attenuated (weakened) influenza vaccine that is sprayed into the nostrils.

MEASLES, MUMPS, RUBELLA (MMR), AND VARICELLA VACCINES
Vaccines for measles, mumps, rubella, and varicella are crucial for preventing these serious diseases. Complications caused by measles virus are ear infection, pneumonia, seizures, brain damage, and death. Mumps virus can lead to deafness, meningitis, painful swelling of the testicles or ovaries, and, in rare cases, sterility. Rubella virus (German measles) contracted by a woman while she is pregnant can cause miscarriage or serious birth defects. Varicella (chicken pox) is a highly infectious disease caused by the varicella zoster virus (VZV). VZV can lead to severe skin infection, scars, pneumonia, brain damage, or death, and can re-emerge years later as shingles.

Children may be administered vaccines for measles, mumps, rubella, and varicella through two separate injections of MMR plus a separate injection of varicella vaccine, or they can be vaccinated with just one injection of the combination measles, mumps, rubella, and varicella vaccine (MMRV). Although MMRV has the benefit of one less injection than MMR plus varicella vaccine, it carries an increased risk for febrile seizures with the first dose for individuals who have a personal or family history of seizures.

MENINGOCOCCAL CONJUGATE AND MENINGOCOCCAL POLYSACCHARIDE VACCINES
Onset can be abrupt, and the course of disease is rapid. Meningococcal disease can lead to serious sequelae (a condition caused by previous disease), including deafness, neurologic deficit, limb loss or possibly death. Rates of meningococcal infection are the highest in infancy, with a second peak in adolescence, especially in individuals around 18 years of age. College freshmen living in dormitories are at higher risk than the general population of similar age.

The disease occurs in three common clinical forms:
  • Meningitis
  • Blood infection
  • Pneumonia

Meningococcal conjugate (MenACWY-D, MenACWY-CRM) and meningococcal polysaccharide (MPSV4) vaccines provide protection against invasive meningococcal disease. In September 2017 the last dose of Hib-MenCY-TT (Menhibrix®) expired.

Some groups may be at increased risk for serogroup B meningococcal disease. Two serogroup B meningococcal (MenB) vaccines have been licensed by the FDA.

PNEUMOCOCCAL VACCINE
Pneumococcal vaccine provides protection against Streptococcus pneumoniae, which can cause sinusitis, acute otitis media (AOM), bacteremia, meningitis, pneumonia, and death. In 2010, 13-valent pneumococcal polysaccharide-protein conjugate vaccine (PCV13) was approved by the US Food and Drug Administration (FDA) to replace 7-valent pneumococcal polysaccharide-protein conjugate vaccine (PCV7) for prevention of invasive pneumococcal disease (IPD). PCV13 contains the seven serotypes that are included in PCV7 (serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F), plus six additional serotypes (1, 3, 5, 6A, 7F, and 19A). The 23-valent pneumococcal polysaccharide vaccine (PPSV23) protects against 23 serotypes of pnemococcal bacteria. In 2017, ACIP no longer recommends PCV7 because all of the healthy children who may have received PCV7 as part of a primary series have now aged out of the recommendation for pneumococcal vaccine.

POLIO VACCINE
Polio, or poliomyelitis, is caused by three serotypes of poliovirus (types 1, 2, and 3). Illness appears in three forms: abortive polio, nonparalytic polio, and paralytic polio. Individuals who have abortive polio or nonparalytic polio can usually recover. However, paralytic polio can cause paralysis and death. Since 2000, ACIP has recommended exclusive use of inactivated poliovirus vaccine (IPV) for routine childhood polio vaccination. In addition, unvaccinated adults who are at increased risk should receive a primary vaccination series with IPV. Oral poliovirus vaccine (OPV) has been removed from the US market since 2000 due to vaccine-associated paralytic poliomyelitis. ACIP only recommends IPV.

ROTAVIRUS VACCINE
Rotavirus vaccine, administered orally, protects against rotavirus, a cause of common, severe gastroenteritis, which can result in the death of infants and young children. Two different rotavirus vaccines are currently available for use in infants in the United States and are given in a series of two or three doses, depending on which brand is used.

ZOSTER (SHINGLES) VACCINE
The zoster (shingles) vaccine protects against VZV. Infection with VZV causes herpes zoster (i.e., shingles), which consists of a painful cutaneous eruption that occurs most commonly among older adults. A complication of herpes zoster is postherpetic neuralgia (PHN), a chronic pain condition that can last years.

Since varicella vaccination in the United States did not begin until 1995, approximately 99.5% of those born in the United States who are 40 years of age and older have had the varicella virus via chicken pox, even if they do not remember. As a result, most older adults in the United States are at risk for herpes zoster. Because of this, health care providers do not need to inquire about the individual's varicella vaccination history before administering zoster vaccine. According to the CDC, "the number of persons eligible for zoster vaccination who have received varicella vaccine is extremely small and will remain so for at least a decade."

NON-ROUTINE VACCINES

Non-routine vaccines, including rabies, anthrax, adenovirus, Bacille Calmette-Guerin (BCG), and typhoid vaccines, are excluded from the immunization schedule recommended by ACIP. Tetanus and diphtheria toxoids (Td) and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) have non-routine indications that are excluded from the immunization schedule recommended by ACIP and are therefore also considered non-routine vaccines under specific circumstances.

ANTHRAX VACCINE
Anthrax is an acute infectious disease caused by the spore-forming bacterium Bacillus anthracis. Anthrax most commonly occurs in wild and domestic animals (e.g., cattle, sheep, goats, and other herbivores), but it can also occur in humans when they are exposed to animals or tissue from animals infected with anthrax spores.

Bacillus anthracis has also been developed specifically as a biological warfare agent. Because the location and timing of a bioterrorism attack cannot be predicted, the risk-benefit profile for pre-event anthrax vaccination for the general public is low; thus, pre-event anthrax vaccination is not recommended by ACIP.

BCG VACCINE
Bacille Calmette-Guerin (BCG) is a vaccine for tuberculosis (TB). Many foreign-born individuals have been BCG-vaccinated. Because the overall risk for acquiring Mycobacterium tuberculosis infection is low for the US population, routine BCG vaccination is not indicated. The BCG vaccine should be considered only for very select individuals who meet specific criteria and in consultation with a TB expert.

POST-EXPOSURE RABIES VACCINE
Rabies is a preventable viral disease of mammals most often transmitted through the bite of a rabid animal. The vast majority of rabies cases reported to the CDC each year occur in wild animals such as raccoons, skunks, bats, and foxes. The rabies virus infects the central nervous system, ultimately causing disease in the brain, and death. The early symptoms of rabies are similar to those of many other illnesses, including fever, headache, and general weakness or discomfort. As the disease progresses, more specific symptoms appear and may include insomnia, anxiety, confusion, slight or partial paralysis, excitation, hallucinations, agitation, hypersalivation (increase in saliva), difficulty swallowing, and hydrophobia (fear of water). Death usually occurs within days of the onset of these symptoms.

ACIP does not recommend pre-exposure prophylaxis against rabies for the general US population or for routine travelers to areas where rabies is not enzootic. However, for individuals who have never been vaccinated against rabies, post-exposure anti-rabies vaccination should be given as soon as possible following an exposure.

Presently, the FDA has only approved the intramuscular route of administration for rabies vaccine.

TDAP/TD VACCINES
In addition to ACIP's routine recommended immunization schedule, TDAP/TD vaccines also provide protection for non-routine indications. Tetanus is caused by a toxin produced by the bacterium Clostridium tetani (C. tetani). C. tetani produces spores that are very difficult to kill. C. tetani spores are found in the soil, the intestines, and the feces of many household farm animals and humans. The bacteria enter the human body through a puncture wound. Wound treatment for tetanus depends on an individual’s vaccination status and the nature of the wound (e.g., severe versus minor and/or contaminated versus clean). With wounds that involve the possibility of tetanus contamination, an individual with an unknown or incomplete history of tetanus vaccination needs a Td or Tdap injection and a dose of tetanus immune globulin (TIG) as soon as possible. An individual with a documented series of three Td or Tdap who has received a booster dose within the last 10 years should be protected. However, to ensure adequate protection, a booster dose of vaccine may still be given if it has been more than 5 years since the last dose and the wound is other than clean and minor.

TYPHOID VACCINE
Typhoid fever is a potentially severe and occasionally life-threatening febrile illness caused by the bacterium Salmonella enterica serotype Typhi. It is most commonly transmitted from water or food contaminated by the feces of an infected individual. It is uncommon in the United States, with an average of 5,700 cases each year.

VACCINES NO LONGER ON THE MARKET

ORAL POLIOVIRUS VACCINE
Oral poliovirus vaccine (OPV) is a mixture of live attenuated poliovirus strains of three serotypes. OPV can cause vaccine--associated paralytic poliomyelitis. Due to this adverse effect, OPV is no longer available on the market in the US.

PLAGUE VACCINE
Plague is a natural infection of rodents and their ectoparasites and occurs in many parts of the world. Yersinia pestis is the causative agent of plague. Epidemic plague may result when domestic rat populations and their fleas become infected. There is currently no plague vaccine available on the market.

TRAVEL-RELATED VACCINES

Certain vaccines are used exclusively for travel purposes, while still other vaccines (both routine and non-routine) that are a part of the recommended immunization schedule or have non-routine indications under specific circumstances are used for travel purposes.

Travel-related vaccines (e.g., yellow fever) should be considered in order to protect travelers from illnesses present in other parts of the world and to prevent the importation of infectious diseases across international borders. Which vaccines are needed depends on a number of factors, including the individual's destination, whether the individual will be spending time in rural areas, the season of the year the individual is traveling, and the individual's age, health status, and previous immunizations. Some countries require travelers to carry proof of vaccination on an International Certificate of Vaccination or Prophylaxis (ICVP) to enter the country; however, requirements can change at any time.

EMPLOYMENT/OCCUPATION--RELATED VACCINES

ACIP recommends vaccination for certain high-risk groups at risk for exposure to and possible transmission of vaccine-preventable diseases. Certain routine vaccines (e.g., hepatitis B vaccine for healthcare personnel) and non-routine vaccines (e.g., adenovirus vaccine for military personnel) will be required and/or recommended by an employer.
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Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR). Use of PCV13 and PPSV23 vaccine for adults with immunocompromising conditions. [CDC Web site]. 10/12/2012. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4.htm. Accessed March 30, 2018.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Use of diphtheria toxoid/tetanus toxoid-acellular pertussis vaccines as a five-dose Series. [CDC Web site]. 12/17/2000. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4913a1.htm. Accessed March 30, 2018.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the Advisory Committee on Immunization Practices. [CDC Web site]. 03/27/2015. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6411a3.htm. Accessed March 30, 2018.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Vaccinia (smallpox) vaccine. [CDC Web site]. 06/22/01. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5010a1.htm. Accessed March 30, 2018.

Centers for Disease Control and Prevention (CDC). The pre-travel consultation. Perspectives: vaccine recommendations of the ACIP. [CDC Web site]. 05/31/2017. Available at: http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-2-the-pre-travel-consultation/the-pre-travel-consultation. Accessed March 30, 2018.

Centers for Disease Control and Prevention (CDC). Travelers' health. Vaccinations. [CDC Web site]. Available at: http://wwwnc.cdc.gov/travel. Accessed March 30, 2018.

Centers for Disease Control and Prevention (CDC). Vaccine information statements. [CDC Web site]. 07/05/2017. Available at: http://www.cdc.gov/vaccines/pubs/vis/default.htm#mmrv .Accessed March 30, 2018.

Centers for Disease Control and Prevention (CDC). Vaccine information statement. Measles, mumps and rubella. [CDC Web site]. 02/12/2018. Available at:
http://www.cdc.gov/vaccines/hcp/vis/vis-statements/mmr.html. Accessed March 30, 2018.

Centers for Disease Control and Prevention (CDC). Why are childhood vaccines so important? [CDC Web site]. 08/18/2017. Available at: http://www.cdc.gov/vaccines/vac-gen/howvpd.htm. Accessed March 30, 2018.

GSK Direct. https://www.gskdirect.com/medias/Menhibrix-Discontinuation-Notice.pdf?context =bWFzdGVyfHJvb3R8NTIyNzQxfGFwcGxpY2F0aW9uL3BkZnxoZTMvaDg1Lzg4NTg3MTMwNjM0NTQucGRmfGYxMjAyMDFmMmU2YjAwYzYyZmUxNWQyNTdjYmUzNjFjMTQ2MDUyODIyMjg4YWIzMTIzNjJhZTZjMWRlNjBlMzg.

Immunization Action Coalition (IAC). Summary of recommendations for adult immunization (age 19 years & older). [IAC Web site] .June 2017. Available at http://www.immunize.org/catg.d/p2011.pdf. Accessed March 30, 2018.

Immunization Action Coalition (IAC). Summary of recommendations for child/teen immunization (ages birth through 18 years). [IAC Web site].June 2017. Available at: http://www.immunize.org/catg.d/p2010.pdf. Accessed March 30, 2018.

Kroger A, Strikas R. General Recommendations for Vaccination and Prophylaxis. [CDC Web site]. 06/13/2017. Available at: http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-2-the-pre-travel-consultation/general-recommendations-for-vaccination-and-immunoprophylaxis. Accessed March 30, 2018.

National Network for Immunization Information (NNii). Hib. [NNii Web site].01/23/2014. Available at: http://www.who.int/immunization/diseases/hib/en/. Accessed March 30, 2018.

US Food and Drug Administration (FDA). FDA product approval: vaccine index. [FDA Web site].11/15/2017. Available at: http://www.immunize.org/fda/. Accessed March 30, 2018.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

MEDICALLY NECESSARY
90585, 90620, 90621, 90630, 90632, 90633, 90636, 90644, 90647, 90648, 90649, 90650, 90651, 90653, 90655, 90656, 90657, 90658, 90661, 90662, 90670, 90672, 90673, 90674, 90675, 90680, 90681, 90682, 90685, 90686, 90687, 90688, 90689, 90690, 90691, 90696, 90698, 90700, 90702, 90707, 90710, 90713, 90714, 90715, 90716, 90723, 90732, 90733, 90734, 90736, 90739, 90740, 90743, 90744, 90746, 90747, 90748, 90750, 90756

EXPERIMENTAL/INVESTIGATIONAL
90587, 90664, 90666, 90667, 90668, 90676, 90697

NOT MEDICALLY NECESSARY
90581

NOT ELIGIBLE FOR REIMBURSEMENT
THE FOLLOWING VACCINE CODES ARE NO LONGER MANUFACTURED AND HAVE BEEN WITHDRAWN FROM THE MARKET:
90634, 90654, 90660

BENEFIT EXCLUSION
90625, 90717, 90738, 90476, 90477

IMMUNIZATION ADMINISTRATION
90460, 90461, 90471, 90472, 90473, 90474


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Report the most appropriate diagnosis code in support of medically necessary criteria as listed in the policy




HCPCS Level II Code Number(s)



MEDICALLY NECESSARY

Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (AFLURIA)

Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLULAVAL)

Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLUVIRIN)

Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)


NOT ELIGIBLE FOR REIMBURSEMENT

THE FOLLOWING VACCINE CODES ARE NO LONGER MANUFACTURED AND HAVE BEEN WITHDRAWN FROM THE MARKET:

Q2034 Influenza virus vaccine, split virus, for intramuscular use (AGRIFLU)

Q2039 Influenza virus vaccine, not otherwise specified


IMMUNIZATION ADMINISTRATION

G0008 Administration of influenza virus vaccine

G0009 Administration of pneumococcal vaccine

G0010 Administration of hepatitis B vaccine

J3530 Nasal vaccine inhalation



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 08.01.04t
01/01/2019The following CPT code has been added to this policy: 90689


Revisions from 08.01.04s
09/03/2018This version of the policy will become effective 09/03/2018. The policy criteria were updated to include travel recommendations for routine vaccinations. Policy criteria were also updated to include live attenuated influenza vaccine as a medically necessary vaccine. The following code position was changed from not medically necessary to medically necessary: 90672.


Revisions from 08.01.04r
05/21/2018The policy criteria was updated to include new recommendations from Advisory Committee on Immunization Practices (ACIP) for Hepatitis B Vaccine and Measles, Mumps, Rubella, and Varicella Vaccine.


Revisions from 08.01.04q
01/01/2018Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.
The following CPT code has been added to this policy: 90756
The following changes were made through a newsflash:
  • The following codes were moved from E/I to MN: 90750, 90739
  • The newsflash communicated 90750 is medically necessary for individuals 50 years and older.


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 01/01/2019
Version Issued Date: 01/03/2019
Version Reissued Date: N/A

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