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Policy Attachment

MA00.003aa
D
MA00.003aa
Vaccines
Preventive Care Services




COVID-19 VACCINE AND ADMINISTRATION
​​The COVID-19 vaccine and administration is considered medically necessary and, therefore, covered for the following indications:
  • Routine one to three-dose vaccination against COVID-19 for individuals ages 6 months and older  
  • A COVID-19 booster vaccination for individuals ages 6 months and older.
  • A three-dose vaccination for individuals who are moderately or severely immunocompromised.

CPT Procedure Code Number(s) and Narrative(s)90480, 91304, ​91318, 91319, 91320, 91321, 91322

ICD-10 Diagnosis Code Number(s) and Narrative(s)N/A
HCPCS Level II Code Number(s) and Narrative(s)N/A

HEPATITIS B VIRUS (HBV) VACCINE AND ADMINISTRATION

COVERAGE
Hepatitis B virus (HBV) vaccine and administration is covered as a preventive service for individuals who are a part of an intermediate- or high-risk group for contracting hepatitis B.
    • Intermediate-risk groups currently identified include:
      • Staff in institutions for the developmentally disabled
      • Workers in health care professions who have frequent contact with blood or blood-derived body fluids during routine work
    • High-risk groups currently identified include:
      • Individuals with end-stage renal disease (ESRD)
      • Individuals with diabetes
      • Individuals with hemophilia who received Factor VIII or IX concentrates
      • Clients of institutions for the developmentally disabled
      • Individuals who live in the same household as an HBV carrier
      • Homosexual men
      • Illicit injectable drug users
HBV vaccine and administration for individuals who are currently positive for antibodies for hepatitis B is not considered a preventive service and, therefore, is not eligible for coverage.

FREQUENCY
Scheduled 2, 3, or 4 doses of the HBV vaccine depending on the selected vaccine and the condition of the individual​ are required to provide complete protection to an individual.

CPT Procedure Code Number(s) and Narrative(s)90739, 90740, 90743, 90744, 90746, 90747, 90759
ICD-10 Diagnosis Code Number(s) and Narrative(s)See Attachment D1
HCPCS Level II Code Number(s) and Narrative(s)G0010 Administration of Hepatitis B Vaccine

INFLUENZA VIRUS VACCINE AND ADMINISTRATION

COVERAGE
Influenza virus vaccine and administration is covered as a preventive service for individuals during the influenza season.

FREQUENCY
Influenza virus vaccine and administration is covered as a preventive service once per year, in the fall or winter.

CPT Procedure Code Number(s) and Narrative(s)
90630, 90653, ​90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 
90672, 90673, 90674, 90682, 90685, 90686, 90687, 90688, 90689, 90694, 
90756
ICD-10 Diagnosis Code Number(s) and Narrative(s)Z23 Encounter for immunization
HCPCS Level II Code Number(s) and Narrative(s)G0008 Administration of influenza virus vaccine

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

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)

Q2039 Influenza virus vaccine, not otherwise specified

PNEUMOCOCCAL VACCINE AND ADMINISTRATION

COVERAGE
An initial pneumococcal vaccine (PCV13) and administration is covered as a preventive service for all individuals who have never received the vaccine.

Pneumococcal vaccine (i.e., PCV15, PCV20, are PPSV23)​ is covered as a preventive service for all individuals.

FREQUENCY
Pneumococcal vaccines (i.e., PCV13, PCV15, PCV20, and PPSV23)  and administration are covered as a preventive service in accordance with the Centers for Disease Control and Prevention (CDC) pneumococcal vaccine timing for adults, as outlined below: 
  • Adults 19 through 64 years of age with certain underlying medical conditions or risk factors (i.e. alcoholism, cerebrospinal fluid leak, chronic heart disease [including congestive heart failure and cardiomyopathies], chronic liver disease, chronic lung disease [including chronic obstructive pulmonary disease, emphysema, and asthma], chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, congenital or acquired immunodeficiencies [including B- (humoral) or T-lymphocyte deficiency, complement deficiencies, and phagocytic disorders excluding chronic granulomatous disease], diabetes, generalized malignancy, HIV infection, Hodgkin disease, iatrogenic immunosuppression [including disease requiring treatment with immunosuppressive drugs, including long-term systemic corticosteroids and radiation therapy], leukemia, lymphoma, multiple myeloma, nephrotic syndrome, sickle cell disease or other hemoglobinopathies, s​olid organ transplants) are recommended:
    • 1 dose of PCV20 OR​​​
    • ​1 dose of PCV15 followed by 1 dose of PPSV23 at least 1 year later​

Note: The minimum interval (8 weeks) can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak


  • Adults 65 years of age or older, are recommended:
    • 1 dose of PCV20  OR​​​​
    • 1 dose of PCV15 followed by 1 dose of PPSV23 at least 1 year later

Note: The minimum interval (8 weeks) can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak


A different, second, pneumococcal vaccine (PPSV23) should be administered 1 year after the first vaccine was administered. (i.e., 11 full months have passed following the month in which the last pneumococcal vaccine was administered).

CPT Procedure Code Number(s) and Narrative(s)90670, 90671, 90677, 90732
ICD-10 Diagnosis Code Number(s) and Narrative(s)Z23 Encounter for immunization
HCPCS Level II Code​ Number(s) and Narrative(s)G0009 Administration of pneumococcal vaccine


ADMINISTRATION AT HOME FOR PNEUMOCOCCAL, INFLUENZA, HEPATITIS B, AND COVID-19 VACCINATION 

When pneumococcal, influenza, hepatitis B, and/or COVID-19 vaccines are medically necessary, a home visit for the sole purpose of administration of pneumococcal, influenza, hepatitis B, and/or COVID-19 vaccines is considered medically necessary and, therefore, covered as a preventive service for individuals who meet either of the following criteria:​

  • ​The individual has difficulty leaving the home to get the vaccine, which could mean any of these: 
    • A condition, due to an illness or injury, that restricts their ability to leave home without a supportive device or help from a paid or unpaid caregiver
    • A condition that makes them more susceptible to contracting a disease
    • Generally unable to leave the home, and if they do leave home, it requires a considerable and taxing effort 
  • The individual i​s hard ​to reach because they have a disability or face clinical, socioeconomic, or geographical barriers to getting a vaccine in settings other than their home. These individuals face challenges that significantly reduce their ability to get vaccinated outside the home, such as challenges with transportation, communication, or caregiving​.​​
​For individuals currently receiving home care services, administration of pneumococcal, influenza, hepatitis B, and/or COVID-19 vaccines are not eligible for separate reimbursement consideration from the home care visit. ​

CPT Procedure Code Number(s) and Narrative(s)
N/A
ICD-10 Diagnosis Code Number(s) and Narrative(s)N/A
HCPCS Level II Code​ Number(s) and Narrative(s)M0201 Administration of pneumococcal, influenza, hepatitis B, and/or COVID-19 vaccine inside a patient's home; reported only once per individual home per date of service when such vaccine administration(s) are performed at the patient's home​


10/01/2024
10/02/2024
N/A
Medical Policy Bulletin
Medicare Advantage
aaf9edcf-bf71-47de-a5f1-e09b853b1422
Yes