The following American Academy of Pediatrics recommended immunizations are covered for individuals who are up to and including 17 years of age for the following diseases:

Diphtheria
Hemophilus Influenza B (HIB)
Hepatitis A
Hepatitis B
Influenza
Meningitis
Mumps
Pertussis (whooping cough)
Pneumonia
Polio
Rubella
Rubeola (measles)
Tetanus
Varicella

NOTE:

Refer to Medical Policy Bulletin I-20 for eligibility guidelines on RSV treatment.

COMVAX (90748), a combination of the hemophilus influenza B (HIB) and hepatitis B vaccines, is a covered immunization procedure.

Pediarix™ (90723), a combination of the DtaP (Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed), Hepatitis B Vaccine (Recombinant), and Inactivated Poliovirus Vaccine (IPV) for administration as one intramuscular injection, is a covered immunization procedure.

Boostrix® (90715) is a combination tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed (Tdap). Boostrix is a covered immunization procedure given as a single dose to individuals aged 10 to 18 years.

Adacel^TM (90715) is a combination tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed (Tdap). Adacel is a covered immunization procedure given as a single dose to individuals aged 11 to 64 years.

ProQuad® (90710) is a combination vaccine of M-M-R® II (Measles, Mumps, and Rubella Virus Vaccine Live) and VARIVAX® (Varicella Virus Vaccine Live). It is indicated for simultaneous vaccination against all four of these diseases in children 12 months to 12 years of age.

Furthermore, reported combinations of the above vaccines are also eligible for payment, e.g., DPT (diphtheria and tetanus toxoids plus pertussis vaccine) is a commonly used combined immunization procedure.

NOTE:

The following codes are applicable to the childhood immunizations listed above: (90633, 90634, 90645, 90646, 90647, 90648, 90655, 90656, 90657, 90658, 90660, 90669, 90698, 90700, 90701, 90702, 90704, 90705, 90706, 90707, 90708, 90710, 90712, 90713, 90714, 90715, 90716, 90718, 90719, 90720, 90721, 90723, 90732, 90733, 90734, 90743, 90744, 90748, S0195). 

NOTE:

FluMist (90660) is an intranasal live virus influenza vaccine for healthy children and adolescents, ages five years to 17 years, and healthy adults, ages 18 to 49. This vaccine is generally not covered. However, coverage may be provided during shortages of the injectable vaccine. A participating, preferred, or network provider can bill the member for the denied service.

OTHER IMMUNIZATIONS

Other than those specific childhood immunizations listed above, coverage for immunizations is determined according to individual or group customer benefits. Immunizations should be reported under the appropriate procedure code. Immunization is acceptable for the following diseases:

Adenovirus
Anthrax
Bladder Cancer
Cholera
Diphtheria
Hemophilus Influenza B (HIB)
Hepatitis A
Hepatitis B
Herpes Zoster (Shingles)
Influenza
Japanese Encephalitis
Lyme Disease
Meningitis
Mumps
Pertussis (whooping cough)
Pneumonia
Plague
Polio
Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18)
Rabies
Rotavirus
Rubella
Rubeola (measles)
Tetanus
Tuberculosis
Typhoid Fever
Varicella
Yellow Fever

DPT (diphtheria and tetanus toxoids plus pertussis vaccine) is a commonly used combined immunization procedure.

Twinrix® (90636), a combination of the hepatitis A virus (HAV; HAVRIX®) and hepatitis B virus (HBV; Energix-B®) vaccines, is a covered immunization procedure for individuals 18 years of age or older.

Adacel^TM (90715) is a combination tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed (Tdap). Adacel is a covered immunization procedure given as a single dose to individuals aged 11 to 64 years.

NOTE:

In addition to the procedure codes listed under the childhood immunizations, the following codes are applicable to the other immunizations: (90476, 90477, 90581, 90585, 90586, 90632, 90636, 90645, 90646, 90647, 90648, 90649, 90656, 90658, 90660, 90665, 90675, 90676, 90680, 90690-90693, 90698, 90701, 90703, 90704, 90705, 90706, 90707, 90708, 90710, 90712, 90713, 90714, 90715, 90716, 90717, 90718, 90719, 90720, 90721, 90723, 90725, 90727, 90732, 90733, 90734, 90735, 90736, 90740, 90746, 90747, 90748, and 90749).

FluMist (90660) is an intranasal live virus influenza vaccine for healthy children and adolescents, ages five years to 17 years, and healthy adults, ages 18 to 49. This vaccine is generally not covered. However, coverage may be provided during shortages of the injectable vaccine. A participating, preferred, or network provider can bill the member for the denied service.

Immunizations or injections for diseases other than those listed above are not eligible for payment. (See Medical Policy Bulletin I-1 for guidelines on rabies injections.)

NOTE:

A separate administration fee can be reported with each separately administered immunization. Codes 90465-90468, 90471-90474 and G0008-G0010 should be reported as appropriate in addition to immunization procedure codes. (This applies to all patients, regardless of age, who have coverage for immunizations.) If codes 90465-90468, 90471-90474, G0008-G0010 are reported as the sole service they will be eligible for payment.

A separate Evaluation & Management (E&M) code can be reported in addition to the administration of an immunization if a significant, separately identifiable E&M service is performed and documented in the patient's medical records.  To justify these services, the patient's records must contain sufficient documentation regarding the appropriateness of performing both services, and documentation that the key components of the E&M service have been met.  If the reported E&M service does not meet the component requirements, it will not be eligible for reimbursement.  Payment for the immunization and the E&M service does not meet the component requirements, it will not be eligible for reimbursement.  Payment for the immunization and the E&M service will also be subject to coverage limitations specified within the individual member's contract. 

See Medical Policy Bulletin I-15 on Hepatitis B vaccine for adults.

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.

Routine immunizations (as licensed by the U.S. Food and Drug Administration), without regard to age, limited to:

• Hepatitis immunization (Types A and B) for patients with increased risk or family history
• Influenza (one each flu season) and pneumococcal vaccines
• Tetanus-diphtheria (Td) booster - once every 10 years
• Herpes Zoster (shingles) vaccines
• Human Papillomavirus (HPV) vaccines

Routine services as recommended by the American Academy of Pediatrics for children up to the age of 22, including children living, traveling, or adopted from outside the United States:

• Meningococcal vaccine
• Human Papillomavirus (HPV) vaccines
• Rotavirus vaccines
• Immunizations

PRN References

06/1993, Immunizations, local code
10/1993, Immunizations pricing
10/1994, Administration of therapeutic injectables and immunizations
03/1995, Immunization administration
08/1995, Chicken pox vaccine
08/1995, Hepatitis A vaccine
12/1996, Immunization administration fees
02/1997, Immunization procedure code 90721 06/1997, FDA approves new immunization procedure
12/1997, Use appropriate codes when reporting immunizations
04/1999, Rotavirus
08/1999, Use specific codes to report respiratory syncytial virus immune globulin
02/2000, FDA orders withdrawal or rotavirus vaccine
02/2000, Eligibility guidelines for influenza, meningococcal, and pneumococcal vaccines
04/2000, Blue Shield may pay for FDA-approved pneumococcal vaccines
10/2000, Blue Shield issues new coverage guidelines for Prevnar™
04/2001, Blue Shield to follow ACIP guidelines for Prevnar™
08/2001, New combination vaccine for hepatitis
04/2003, Pediarix™ vaccine eligible for payment
10/2003, FluMist not eligible for payment
06/2005, New vaccine Menactra eligible for payment
08/2005, Decavac^TM eligible for coverage
08/2005, Boostrix® eligible for coverage
08/2005, New immune globulin, VIGIV, eligible for payment
10/2005, New vaccine Adacel^TM eligible for coverage
12/2005, New vaccine ProQuad® eligible for coverage
12/2005, New vaccine FLUARIX^TM eligible for coverage
06/2006, RotaTeq^TM eligible for coverage
10/2006, New HPV vaccine GARDASIL® eligible for coverage
10/2006, ZOSTAVAX® coverage explained

Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP), Morbidity/Mortality Weekly Report, 49 (RR-03); 1-38, 4/2000

Control and Prevention of Meningococcal Disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP), Morbidity/Mortality Weekly Report, 46 (RR-5); 1-51, 2/1997

Prevention of Pneumococcal Disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP), Morbidity/Mortality Report, 46 (RR-08); 1-24, 4/1997

Immunizations of Adolescents: Recommendations of the Advisory Committee on Immunization Practices, The American Academy of Pediatrics, The American Academy of Family Physicians, and the American Medical Association, American Academy of Pediatrics, Vol. 99, No. 3, 3/1997

Recommendations for the Prevention of Pneumococcal Infections, Including the Use of Pneumococcal Conjugate Vaccine (Prevnar), Pneumococcal Polysaccharide Vaccine, and Antibiotic Prophylaxis (RE9960), American Academy of Pediatrics, Policy Statement, Vol. 106, No. 02, August, 2000 Act 35 of 1992

Combined Tetanus, Diphtheria, and 5-Component Pertussis Vaccine for Use in Adolescents and Adults, JAMA,, Vol. 293, No. 24, June 2005