Medicare Advantage Medical Policy Bulletin
Section: Injections
Number: I-8
Topic: Use of Vaccines or Inoculations for Treatment of Injury or Exposure
Effective Date: December 12, 2008
Issued Date: March 16, 2009

General Policy

For services on or after June 29, 2009, see policy N-82.

Vaccination is a method of producing immunity against a specific organism.

Indications and Limitations of Coverage

The Centers for Medicare and Medicaid Services (CMS) Medicare Benefit Policy Manual (IOM 100-02), Chapter 15, Section 50.4.4.2, states the following regarding the use of Immunizations: "Vaccinations or inoculations are excluded as immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, such as anti-rabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenin sera, or immune globulin. In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation against such diseases as smallpox, polio, diphtheria, etc.), is not covered. However, pneumococcal, hepatitis B, and influenza virus vaccines are exceptions to this rule." It further states: "In cases where a vaccination or inoculation is excluded from coverage, related charges are also not covered."

NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

Coding Guidelines

Use of a vaccine or inoculation by a provider for the treatment of an injury or direct exposure, as described above, should be indicated by the use of the AT modifier on the submitted claim.

Refer to Medicare Advantage Medical Policy Bulletin I-6, Approved Drugs and Biologicals for additional information concerning drugs and biologicals.

Publications

References

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS IOM Pub. 100-02, Chapter 15, Section 50.4.4.2

CMS IOM Pub. 100-04, Chapter 17, Section 10

Highmark Medicare Services Part B Reference Manual, Chapter 25, Preventive Services

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.