ARBenefits Approval: 01/01/2012 Effective Date: 01/01/2012 Revision Date: 03/24/2014 Code(s): Many Medical Policy Title: Immunization Coverage Document: ARB0454:04 Administered by: Public Statement: 1. Immunizations recommended for routine administration to children and adults by the Center for Disease Control of the US Department of Health, or similarly authoritative body, will be covered under the preventive medicine benefit. Coverage includes payment both for the cost of the immunization materials and for the administration fee. Immunizations not covered as routine and which are intended primarily for travel, or required for work, school or camp, are not covered. 2. Immunizations other than those recommended for routine use may be required for medical indications, such as exposure to a potentially rabid animal. These immunizations will be covered under the if they are determined to be medically necessary. 3. Influenza immunization (flu shots) will be covered at any location provided; no prescription is required. Human Papilloma Virus (Gardisil) and Shingles immunizations are covered through the pharmacy or at a physician s office. (Shingles vaccine requires a prescription from a physician). All other covered immunizations must be provided through a physician s office. Medical Policy Statement: An immunization is a routinely administered medication to prevent a specific disease in someone with a normally functioning immune system. Some immunizations are offered at sites other than a physician s office, such as a retail pharmacy. ARBenefits believes that immunizations should be directed by and coordinated by the patient s physician. Infant Through age 6 Immunizations: The following immunizations for children age birth to 6 years of age are recommended by the Center for Disease Control and the National Immunization Program. (See Attachment A: Recommended Childhood Immunization Schedule and Catch up Schedule for Children and Adolescents.) Page 1 of 10
90633, 90634 - Hepatitis A (age 12 months or older) 90645-90648 - Hemophilus influenza type B 90655, 90657, 90685, 90687 Influenza for children age 6 months to 3 years 90656, 90658, 90686, 90688 Influenza 3 years and older 90660, 90672 Influenza, live, attenuated (age 2 years or older) 90669 - Pneumococcal Conjugate Vaccine 7 valent 90670 Pneumococcal Conjugate Vaccine 13 valent 90680 Rotavirus (RotaTeq) (maximum age for the first dose 14 weeks and 6 days; maximum age for the last dose 32 weeks 0 days) 90681 Rotavirus (Rotarix) (first dose at 6 weeks, second dose before 24 weeks) 90696 DtaP-IPV (ages 4 through 6) 90698 - DTaP-Hib-IPV 90700 - DTaP 90701 - DPT 90702 - DT (tetanus/diphtheria, child) 90704 - Mumps Virus 90705 - Measles Virus 90707 - MMR 90708 - Measles Rubella 90710 - MMR Varicella 90713 Inactivated Polio 90716 Varicella (age 12 months or older) 90719 Diphtheria 90720 - DTP-Hib 90721 - DTaP-Hib 90723 - DTaP-HepB-IPV 90732 Pneumococcal polysaccharide vaccine (age 2 years and older) 90744 Hepatitis B, pediatric/adolescent dosage (one series per lifetime) 90748 Hepatitis B and Hemophilus influenza b 90732 Pneumococcal polysaccharide vaccine (PPSV), 23 valent (age 2 years and older) 90733, 90734 Meningococcal vaccine Adolescent (ages 7 through 18 years) Immunizations: 90633, 90634 - Hepatitis A 90649 Human Papilloma virus (HPV) quadrivalent (males or females age 9 or older) 90650 Human Papilloma Virus (HPV) bivalent (females age 9 and older) 90656, 90658, 90660 Influenza 90670 Pneumococcal conjugate vaccine 13-valent 90704 - Mumps Virus 90705 - Measles Virus 90707 - MMR Page 2 of 10
90708 - Measles Rubella 90710 - MMR Varicella 90713 Inactivated Polio 90715 Tdap (tetanus, diphtheria, acellular pertussis, adult) 90716 Varicella 90719 Diphtheria 90732 Pneumococcal polysaccharide vaccine 90733, 90734 Meningococcal vaccine 90743, 90744 - Hepatitis B (one series per lifetime) Adults (age 19 and older): 90632 Hepatitis A (through age 24) 90649 HPV quadrivalent (males through age 26, females through age 26) 90656, 90658, 90686, 90688 Influenza 90660, 90672 Influenza, live attenuated (through age 49 years) 90662 Influenza, hi dose (age 65 and over) 90703 - T (tetanus) every ten years 90706 - Rubella virus 90715 Tdap (tetanus, diphtheria, acellular pertussis, adult) once 90718 - Td (tetanus/diphtheria, adult) every ten years 90719 Diphtheria, every ten years 90732 - Pneumococcal Polysaccharide Vaccine 90733, 90734 Meningococcal vaccine 90736 Zoster (shingles) (age 50 and older) 90746 Hepatitis B (one series per lifetime) Influenza Immunization: (90657-90660, 90672, 90685-90688): The CDC and the American Academy of Pediatrics recommend influenza vaccination for children between 6 months and 23 months of age during flu season. Annual influenza vaccination is recommended for all children ages 6 months and older with high risk conditions. Adults will be covered as recommended by the CDC. Influenza vaccination will be covered at any location without requirement for a physician s prescription. Immunizations Not Routinely Covered: The following sections detail immunizations which are not routinely covered. They may be requested by a member for reasons particular to that member, and be administered by an attending physician who agrees with the need despite the expectation that ARBenefits will not pay for the immunization. In such cases, a specific statement of acknowledgement of financial responsibility (similar to the Medicare ABN) should be signed by the member before the immunization is administered, to advise the member of his/her financial responsibility, and the amount of that responsibility. The member should be advised that the claim may be denied by ARBenefits with no recognition of member liability, but that this does not release the member from financial responsibility to pay for the requested immunization. Page 3 of 10
Immunizations Subject to Medical Review: The following immunizations are covered under the when ordered by a physician and will be subject to medical necessity review: Adenovirus (90476-90477) Rabies (90675, 90676) for those with confirmed or presumed rabies exposure. Immunizations required due to outbreak of disease in Arkansas will be covered as medically necessary and reported to the Arkansas Department of Health. These immunizations are subject to medical necessity review: 90581 - Anthrax 90725 - Cholera 90691-90693 - Typhoid 90727 - Plague vaccine 90665 - Lyme Disease vaccine 90749 - Unlisted vaccines Immunizations Not Covered Immunizations not mentioned above as being routinely covered are not a covered benefit even when required for: Travel Employment Camp Attendance at school New vaccines, new combination vaccines, and vaccines given through alternative routes will be reviewed as needed for medical necessity and for appropriateness of coverage according to the member s benefit contract. New vaccines that are duplicates of already available vaccines, or which are different only because of reduced amounts of preservative in them, are not covered unless there is some scientifically demonstrated reason to believe that they are superior. If they are not shown to be superior, they may be covered if the vaccine is available at the same or lower price compared to the standard vaccine. The following immunizations are not covered because they are obsolete, there are better methods to prevent infection than immunization or they are used exclusively for travel: 90585-90586 BCG vaccine 90735 - Japanese encephalitis vaccine (used only for travel) 90717 - Yellow Fever (used only for travel) 90712 Oral Polio (obsolete) Codes Used In This BI: 90476 Adenovirus vaccine type 4 Page 4 of 10
90477 Adenovirus vaccine type 7 90581 Anthrax vaccine sc or im 90585 Bcg vaccine percut 90586 Bcg vaccine intravesical 90632 Hep a vaccine adult im 90633 Hep a vacc ped/adol 2 dose 90634 Hep a vacc ped/adol 3 dose 90636 Hep a/hep b vacc adult im 90644 Meningoccl hib vac 4 dose im 90645 Hib vaccine hboc im 90646 Hib vaccine prp-d im 90647 Hib vaccine prp-omp im 90648 Hib vaccine prp-t im 90649 Hpv vaccine 4 valent im 90650 Hpv vaccine 2 valent im 90654 Flu vaccine no preserv id 90655 Flu vaccine no preserv 6-35m 90656 Flu vaccine no preserv 3 & > 90657 Flu vaccine 3 yrs im 90658 Flu vaccine 3 yrs & > im 90660 Flu vaccine nasal 90661 Flu vacc cell cult prsv free 90662 Flu vacc prsv free inc antig 90664 Flu vacc pandemic intranasal 90665 Lyme disease vaccine im 90666 Flu vac pandem prsrv free im 90667 Flu vac pandemic adjuvant im 90668 Flu vac pandemic splt im 90669 Pneumococcal vacc 7 val im 90670 Pneumococcal vacc 13 val im 90672 Influenza, quadrivalent, attenuated 90675 Rabies vaccine im 90676 Rabies vaccine id 90680 Rotavirus vacc 3 dose oral 90681 Rotavirus vacc 2 dose oral 90685 Influenca,quadrivalent,,6-35 mo 90686 Influenza, quadrivalent, >35 mo 90687 Influenza, quadrivalent, 6-35 mo 90688 Influenza, quadrivalent, >35 mo 90690 Typhoid vaccine oral 90691 Typhoid vaccine im 90692 Typhoid vaccine h-p sc/id 90693 Typhoid vaccine akd sc 90696 Dtap-ipv vacc 4-6 yr im Page 5 of 10
90698 Dtap-hib-ip vaccine im 90700 Dtap vaccine < 7 yrs im 90701 Dtp vaccine im 90702 Dt vaccine < 7 im 90703 Tetanus vaccine im 90704 Mumps vaccine sc 90705 Measles vaccine sc 90706 Rubella vaccine sc 90707 Mmr vaccine sc 90708 Measles-rubella vaccine sc 90710 Mmrv vaccine sc 90712 Oral poliovirus vaccine 90713 Poliovirus ipv sc/im 90714 Td vaccine no prsrv >/= 7 im 90715 Tdap vaccine >7 im 90716 Chicken pox vaccine sc 90717 Yellow fever vaccine sc 90718 Td vaccine > 7 im 90719 Diphtheria vaccine im 90720 Dtp/hib vaccine im 90721 Dtap/hib vaccine im 90723 Dtap-hep b-ipv vaccine im 90725 Cholera vaccine injectable 90727 Plague vaccine im 90732 Pneumococcal vaccine 90733 Meningococcal vaccine sc 90734 Meningococcal vaccine im 90735 Encephalitis vaccine sc 90736 Zoster vacc sc 90738 Inactivated je vacc im 90740 Hepb vacc ill pat 3 dose im 90743 Hep b vacc adol 2 dose im 90744 Hepb vacc ped/adol 3 dose im 90746 Hep b vaccine adult im 90747 Hepb vacc ill pat 4 dose im 90748 Hep b/hib vaccine im 90749 Vaccine toxoid References 1. CDC Recommendations for Lyme disease vaccine. www.cdc.gov/nip 2. American Academy of Pediatrics recommendations, http://www.aap.org/ Page 6 of 10
3. American Academy of Family Practice Physicians recommendations, http://www.aafp.org/ 4. National Immunization Information Hotline: 800-232-2552 5. ACIP recommendations: CDC website. 6. Prevention and control of meningitis, recommendations of the Advisory Committee on Immunization Practices at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5407a1.htm 7. Health and Economic Implications of HPV Vaccination in the United States: NEJM August 2008 at: http://content.nejm.org/cgi/content/full/359/8/821 8. CDC Immunization schedules at; http://www.cdc.gov/vaccines/recs/schedules/ Immunization Adenovirus CPT code 90476-90477 Age (in years, unless otherwise specified) Anthrax 90581 90585- BCG (TB vaccine) 90586 Not covered Cholera 90725 Diphtheria 90719 any DT and combinations 90698, 90700, 90701, 90702, 90720, 90721, 90723 6 DTaP-IPV 90696 4-6 Hemophilus influenza Type B 90645-90648 6 Hep B/Hib 90748 6 90362- Hepatitis A 90634 1-24 Gender if specified Frequency Comments Requires record review to determine Medical Necessity Covered when Medically Necessary during an outbreak of disease Series depends on combination four three series of two two Covered when Medically Necessary during an outbreak of disease Page 7 of 10
Hepatitis B, adolescent 90743 11-15 Hepatitis B, adult 90746 19 three three Hepatitis B, pediatric/adolescent 90744 18 three HPV (Human Papilloma Virus) bivalent 90650 Not covered Female HPV (Human Papilloma Virus) quadrivalent 90649 9-26 Both three 90655, 90657, 90685, Influenza 90687 6 mo to 35 mo annual 90656, 90658, 90686, Influenza 90688 3-64 annual 90662, Influenza, high dose 90672 65 annual Influenza, live attenuated 90660 2-49 annual Japanese Obsolete; quadrivalent is preferred encephalitis 90735 Not covered Travel vaccine Lyme Disease 90665 Meningococcal 90733, vaccine 90734 any 90704, 90705, 90707, 90708, series of MMRV and subsets 90710 18 two Oral polio 90712 Not covered Obsolete Plague 90727 Pneumococcal Conjugate 13 valent 90670 < 7 years series of four Covered when Medically Necessary during an outbreak of disease Covered when Medically Necessary during an outbreak of disease Pneumococcal Conjugate 7 valent 90669 < 6 years 13 valent is preferred Page 8 of 10
Pneumococcal polysaccharide (23 valent) 90732 2 two, at least five years apart Polio, inactivated 90713 18 total of four Rabies 90675-90676 Rotarix (rotavirus) 90681 6 weeks to 8 months two Rotateq (rotavirus) 90680 6 weeks to 8 months Rubella 90706 19 TdaP 90715 > 6 Once 90703, Tetanus/Td 90718 19 Typhoid 90691-90693 Unlisted vaccines 90749 three every 10 years two Recommended for all adults over age 64, and for high risk adults age 19-64. Recommended for high risk children over age 2 who have completed the 13- valent pneumococcal series. Requires record review to determine Medical Necessity Maximum age for first dose is 14 weeks and 6 days Maximum age for first dose is 14 weeks and 6 days Covered when Medically Necessary during an outbreak of disease Requires record review to determine Medical Necessity Varicella 90716 1-18 Yellow fever 90717 Not covered Travel vaccine Zoster 90736 50 Once Application to Products This policy applies to ARBenefits. Consult ARBenefits Summary Plan Description (SPD) for additional information. Last modified by: SCS Date: 03/24/2014 Page 9 of 10
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