Mountain State Medical Policy Bulletin
Section: Injections
Number: I-8
Topic: Immunizations
Effective Date: September 15, 2009
Issued Date: September 21, 2009
Date Last Reviewed: 09/2009

General Policy Guidelines

Indications and Limitations of Coverage

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
Rotavirus
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.

Kinrix™ (90696) a combination of the Diphtheria and Tetanus Toxoids and Acellular Pertussis (Adsorbed) and Inactivated Poliovirus Vaccine.

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.

Pentacel® (90698) a combination of the Diphtheria and Tetanus Toxoids and Acellular Pertussis (Adsorbed), Inactivated Poliovirus and Haemophilus b Conjugate (Tetanus Toxoid Conjugate) Vaccine.

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.

AdacelTM (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, 90681, 90696, 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, G9142, and 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.

AdacelTM (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.

BoostrixTM (90715) is a combination tetanus toxoid reduced diptheria toxoid and acellular pertussis vaccine adsorbed (Tdap).

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, 90681, 90690-90693, 90696, 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, 90738, 90740, 90746, 90747, 90748, 90749 and G9142).

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. A participating, preferred, or network provider can bill the member for the denied service.

NOTE:
A separate administration fee can be reported with each separately administered immunization. Codes 90465-90468, 90471-90474, G0008-G0010, and G9141 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, and G9141 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.

Procedure Codes

902819028390284902889037190375
903769037890379903849038590386
903899039390396904659046690467
904689047190472904739047490585
906329063390634906369064590646
906479064890649906559065690657
906589066090669906759067690680
906819069090691906929069690698
907009070190702907039070490705
907069070790708907109071290713
907149071590716907179071890719
907209072190723907259072790732
907339073490735907369073890740
907439074490746907479074890749
G0008G0009G0010J1460J1470J1480
J1490J1500J1510J1520J1530J1540
J1550J1560J1562J1565J1566J1570
J1571J1573J1670J2790J2791G9141
G9142S0195    

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

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
Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

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

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

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

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

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

Delayed Onset and Diminished Magnitude of Rotavirus Activity - United States, November 2007 - May 2008, Morbidity/Mortality Weekly Report, 57;1-4, June 25, 2008

US Food and Drug Administration (FDA). FDA approves new vaccine to prevent Japanese Encephalitis. FDA News. Rockville, MD: FDA; March 30, 2009.

GlaxoSmith Kline Biologicals, Boostrix® (Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine, Adsorbed). Prescribing Information. Research Triangle Park, NC: January, 2009.

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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 Mountain State Blue Cross Blue Shield 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.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.