Benefit Interpretation

Transcription

1 Benefit Interpretation Subject: Part B vs. Part D Vaccines Issue Number: BI-039 Applies to: Medicare Advantage Effective Date: May 1, 2017 Attachments: Part B Vaccines Diagnosis Code Limits Table of Contents Purpose... 1 Coverage Guidelines... 1 Applicable Codes... 2 Exclusions and Limitations... 8 Definitions... 8 References... 8 Revision History... 9 Purpose This Benefit Interpretation provides assistance in interpreting Florida Hospital Care Advantage s immunization coverage for Medicare Advantage plan members. When deciding coverage, the member specific benefit plan document must be referenced [i.e., Evidence of Coverage (EOC)]. In the event of a conflict between the benefit plan document and this Benefit Interpretation, the member specific benefit plan document will prevail. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the member specific benefit plan coverage prior to use of this Benefit Interpretation. Other policies and Benefit Interpretations may apply. Florida Hospital Care Advantage reserves the right, in its sole discretion, to modify its policies and guidelines as necessary. This Benefit Interpretation is provided for informational purposes. It does not constitute medical advice, nor guarantee coverage. Coverage Guidelines Coverage Rationale Florida Hospital Care Advantage covers immunizations in accordance with Medicare guidelines. The way immunizations are covered depends on the vaccine needed. Immunizations covered under the Part B medical benefit include: Hepatitis B vaccine (for beneficiaries at high or intermediate risk), Influenza (flu) virus vaccine, Pneumococcal pneumonia vaccine, and Document Owner: HFHP Government Programs Page 1 of 9

2 Vaccines directly related to the treatment of an injury or direct exposure to a disease or condition. (For example, if a beneficiary steps on a rusty nail, Part B will cover a tetanus shot. If a beneficiary is bitten by a dog, Part B will cover a rabies shot.) All other vaccines are covered under the Part D prescription drug benefit. Part B Coverage Information The influenza (flu) virus vaccine, pneumococcal pneumonia vaccine, and Hepatitis B vaccine are covered without cost-share for beneficiaries receiving these services from a network provider. For the Hepatitis B vaccine, coverage is limited to those who are at high or intermediate risk of contracting Hepatitis B. High-risk beneficiaries include: Persons diagnosed with ESRD Hemophiliacs who receive Factor VIII or IX concentrates Patients of institutions for the mentally retarded Persons who live in the same household as a hepatitis B virus (HBV) carrier Homosexual men Illicit injectable drug abusers Persons diagnosed with diabetes mellitus Intermediate risk beneficiaries include: Staff in institutions for the mentally retarded Persons in health care professions who have frequent contact with blood or bloodderived body fluids during routine work Vaccines directly related to the treatment of an injury or direct exposure to a disease or condition are subject to the Part B drug cost-share outlined in the beneficiary s Evidence of Coverage (EOC). Part D Coverage Information All commercially available vaccines not covered under Part B are covered under the Part D prescription drug benefit, as long as the vaccine is reasonable and necessary to prevent illness. Covered vaccines are identified in the Health Plan s formulary (drug list). Cost-share varies according to the coverage tier, and special rules (such as prior authorization, step therapy and quantity limits) may apply. Applicable Codes The following vaccinations and their administration are covered as a Part B benefit. CPT/HCPCS Code Influenza Vaccine: Covered under the Part B benefit, regardless of the setting in which the vaccine is furnished Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use Document Owner: HFHP Government Programs Page 2 of 9

3 90653 Influenza vaccine, inactivated, subunit, adjuvanted, for Influenza virus vaccine, trivalent (IIV3), split virus, preservative-free, for intradermal use Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when administered to children 6-35 months of age, for Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when administered to individuals 3 years and older, for Influenza virus vaccine, trivalent (IIV3), split virus, when administered to children 6-35 months of age, for Influenza virus vaccine, trivalent, live (LAIV3), for intranasal use Influenza virus vaccine (cciiv3), derived from cell cultures, subunit, preservative and antibiotic free, for Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3), hemagglutnin (HA) protein only, preservative and antibiotic free, for Influenza virus vaccine, quadrivalent (cciiv4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 ml dosage, for Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for [Effective July 1, 2017] Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to children 6-35 months of age, for Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to individuals 3 years of age and older, for Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to children 6-35 months of age, for Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to individuals 3 years of age and older, for J3530 Nasal vaccine inhalation (children aged 2 12) Q2034 Q2035 Influenza virus vaccine, split virus, for (Agriflu) and older, for (AFLURIA) Document Owner: HFHP Government Programs Page 3 of 9

4 Q2036 Q2037 Q2038 Q2039 and older, for (FLULAVAL) and older, for (FLUVIRIN) and older, for (Fluzone) and older, for (not otherwise specified Influenza Immunization Administration: Covered under the Part B benefit, regardless of the setting in which the vaccine is furnished. G0008 Administration of influenza virus vaccine Pneumococcal Vaccine: Covered under the Part B benefit, regardless of the setting in which the vaccine is furnished Pneumococcal conjugate vaccine, 13 valent (PCV13), for Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or Pneumococcal Immunization Administration: Covered under the Part B benefit, regardless of the setting in which the vaccine is furnished. G0009 Administration of pneumococcal vaccine The following vaccinations and their administration are covered as a Part B benefit when a claim is submitted with one of the specific diagnosis codes referenced. In the absence of the specified diagnoses, these vaccines should be processed under the Part D prescription drug benefit. CPT/HCPCS Code Hepatitis B Vaccine: Part B coverage is limited to individuals who are at high or intermediate risk for contracting Hepatitis B. See the Part B Vaccines Diagnosis Code Limits Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule, for Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3 dose schedule, for Hepatitis B vaccine (HepB), adolescent, 2 dose schedule, for Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3 dose schedule, for Document Owner: HFHP Government Programs Page 4 of 9

5 90746 Hepatitis B vaccine (HepB), adult dosage, 3 dose schedule, for Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 4 dose schedule, for Hepatitis B Immunization Administration: Part B coverage criteria for Hepatitis B vaccine must be met in order for the administration to be covered under the Part B benefit. G0010 Administration of hepatitis B vaccine Rabies Vaccine: Covered under the Part B benefit when administered as a result of an encounter with an animal that is at high-risk for rabies. See Part B Vaccines Diagnosis Code Limits Rabies vaccine, for Rabies vaccine, for intradermal use Tetanus Vaccine: Covered under the Part B benefit when administered for treatment of an injury. See Part B Vaccines Diagnosis Code Limits Diphtheria and tetanus toxoids (DT) adsorbed when administered to individuals younger than 7 years, for Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when administered to individuals 7 years or older, for Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for Tetanus and/or Rabies Immunization Administration: Part B coverage criteria for tetanus and rabies vaccines must be met in order for the administration to be covered under the Part B benefit Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) Document Owner: HFHP Government Programs Page 5 of 9

6 The following vaccinations and their administration are covered exclusively under the Part D prescription drug benefit. Please reference the applicable formulary for coverage details. CPT/HCPCS Code Bacillus Calmette-Guerin (BCG) Vaccine Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use Diphtheria, Tetanus, Pertussis (DTap, Tdap or DT) Vaccine Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated (DTaP-IPV), when administered to children 4 through 6 years of age, for Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenza type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae type b, and inactivated poliovirus vaccine (DTaP-IPV/Hib), for Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DTaP-HepB-IPV), for Haemophilus Influenza Type B (Hib) Vaccine Haemophilus influenzae b vaccine (Hib), PRP-OMP conjugate, 3 dose schedule, for Haemophilus influenzae b vaccine (Hib), PRP-T conjugate, 4 dose schedule, for Hepatitis A Vaccine Hepatitis A vaccine (HepA), adult dosage, for Hepatitis A vaccine (HepA), pediatric/adolescent dosage-2 dose schedule, for Hepatitis A vaccine (HepA), pediatric/adolescent dosage-3 dose schedule, for Hepatitis A and B Vaccine Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for Document Owner: HFHP Government Programs Page 6 of 9

7 Herpes Zoster (Shingles) Vaccine Zoster (shingles) vaccine (HZV), live, for subcutaneous injection Human Papilloma Virus (HPV) Vaccine Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 3 dose schedule, for Inactivated Poliovirus (IPV) Vaccine Poliovirus vaccine, inactivated (IPV), for subcutaneous or Japanese Encephalitis Virus Vaccine Japanese encephalitis virus vaccine, inactivated, for Measles, Mumps, Rubella (MMR) Vaccine Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use Meningococcal Vaccine Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B (MenB), 2 dose schedule, for Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB), 3 dose schedule, for Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus influenzae type b vaccine (Hib-MenCY), 4 dose schedule, when administered to children 6 weeks-18 months of age, for Meningococcal polysaccharide vaccine, serogroups A, C, Y, W-135, quadrivalent (MPSV4), for subcutaneous use Meningococcal conjugate vaccine, serogroups A, C, Y and W-135, quadrivalent (MenACWY), for Rotavirus Vaccine Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, for oral use Document Owner: HFHP Government Programs Page 7 of 9

8 90681 Rotavirus vaccine, human, attenuated (RV1), 2 dose schedule, live, for oral use Unlisted Vaccine/Toxoid Unlisted vaccine/toxoid Varicella Vaccine Varicella virus vaccine (VAR), live, for subcutaneous use Exclusions and Limitations General Exclusions Vaccines purchased or received from any source, including a pharmacy, outside the United States are excluded from coverage. Excluded Codes CPT/HCPCS Code Influenza Vaccine and older, for Definitions Vaccination: An injection of a killed microbe in order to stimulate the immune system against the microbe, thereby preventing disease. Vaccinations, or immunizations, work by stimulating the immune system, the natural disease-fighting system of the body. The healthy immune system is able to recognize invading bacteria and viruses and produce substances (antibodies) to destroy or disable them. Immunizations prepare the immune system to ward off a disease. To immunize against viral diseases, the virus used in the vaccine has been weakened or killed. To only immunize against bacterial diseases, it is generally possible to use a small portion of the dead bacteria to stimulate the formation of antibodies against the whole bacteria. In addition to the initial immunization process, it has been found that the Effectiveness of immunizations can be improved by periodic repeat injections or "boosters." References Medicare Benefit Policy Manual Chapter 15 Covered Medical and Other Health Services, Section Document Owner: HFHP Government Programs Page 8 of 9

9 Medicare Claims Processing Manual Chapter 18 Preventive and Screening Services MLN Matters Article MM9876, Implementation of New Influenza Virus Vaccine Code Article MM8249, New Influenza Virus and Hepatitis B Virus Vaccine Codes Article MM9051, Modifications to Medicare Part B Coverage of Pneumococcal Vaccinations Article MM7234, New HCPCS Q-codes for Seasonal Influenza Vaccines Medicare Learning Network Medicare Part B Immunization Billing, ICN December 2016 Medicare Preventive Services, ICN October 2016 Vaccine and Vaccine Administration Payments Under Medicare Part D, ICN March 2016 Other Sources Florida Hospital Care Advantage Medicare Advantage Evidence of Coverage, Chapter 4 Revision History Version ID Date Action/Description of Change BI /01/2017 N/A First publication This document was created for informational use by Florida Hospital Care Advantage s internal staff and participating providers only. It will not be approved by the Center for Medicare & Medicaid Services (CMS) and cannot be released to any member. Florida Hospital Care Advantage is administered by Health First Health Plans. Health First Health Plans is an HMO plan with a Medicare contract. Enrollment in Health First Health Plans depends on contract renewal. Health First Commercial Plans, Inc. is doing business under the name of Florida Hospital Care Advantage. Florida Hospital Care Advantage does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations. Document Owner: HFHP Government Programs Page 9 of 9