Childhood Immunization Insurance Act (Act 35 of 1992)
CHILDHOOD IMMUNIZATIONS (Effective 11/21/1992)

The following immunizations are covered for dependent children as well as applicant/members and their spouses who are up to and including 20 years of age:

Diphtheria
Hemophilus B (HIB)
Hepatitis B
Mumps
Pertussis (whooping cough)
Polio
Respiratory Syncytial Virus (RSV)
Rubella
Rubeola (measles)
Tetanus
Varicella (chicken pox vaccine-90716)

In addition, the following immunizations are covered for dependent children as well as applicant/members and their spouses who are up to and including 20 years of age and who are medically high-risk individuals as defined by the criteria below. (Refer to the "References" section of this policy regarding these Advisory Committee on Immunization Practices (ACIP) recommendations.)

Influenza (90657, 90658, 90659)

• Residents of nursing homes and other chronic-care facilities that house persons of any age who have chronic medical conditions.

• For children greater than six months of age who have chronic disorders of the pulmonary or cardiovascular systems, including children with asthma, children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression caused by medications), children or teenagers who are receiving long term aspirin therapy and therefore may be at risk for developing Reye's syndrome after influenza.

• Household members (including children) of persons in high-risk groups.
  

Routine vaccination of civilians with the quadrivalent meningococcal polysaccharide vaccine is not recommended because of its relative ineffectiveness in children less than two years of age (among whom risk for endemic disease is highest) and its relatively short duration of protection. However, the polysaccharide meningococcal vaccine is useful for controlling serogroup C meningococcal outbreaks.

In general, use of polysaccharide meningococcal vaccine should be restricted to persons greater than or equal to two years of age. However, children as young as three months of age may be vaccinated to elicit short-term protection against serogroup A meningococcal disease (two doses administered three months apart should be considered for children 3-18 months of age).

Routine vaccination with the quadrivalent vaccine is recommended for certain high-risk groups, including persons who have terminal complement component deficiencies, and those who have anatomic or functional asplenia. Persons whose spleens have been removed because of trauma or nonlymphoid tumors and persons who have inherited complement deficiencies have acceptable antibody responses to meningococcal vaccine. However, the clinical efficacy of vaccination has not been documented for these persons, and they may not be protected by vaccination. Research, industrial and clinical laboratory personnel who routinely are exposed to N. meningitidis in solutions that may be aerosolized should be considered for vaccination.

Highmark Blue Cross Blue Shield does not recognize pre-college admission, or ongoing college attendance as high risk per the above criteria. Therefore, meningococcal vaccination would not be covered. A participating/preferred provider may bill the member for the vaccine.

Pneumococcal

Pneumococcal Polysaccharide Vaccine, 23-valent (90732)
The vaccine is both cost effective and protective against pneumococcal infection when administered to immunocompetent persons two years of age or older. Therefore, all persons in the following categories should receive the 23-valent pneumococcal polysaccharide vaccine. If earlier vaccination status is unknown, persons in these categories should be administered pneumococcal vaccine.

• Persons two years of age or older who are at increased risk for pneumococcal disease or its complications if they become infected should be vaccinated. Persons at increased risk for severe disease include those with chronic illness such as chronic cardiovascular disease (e.g., congestive heart failure {CHF} or cardiomyopathies), chronic pulmonary disease (e.g., COPD or emphysema, but not asthma), diabetes mellitus, alcoholism, chronic liver disease (cirrhosis), or cerebrospinal fluid leaks.

• Persons two years of age or older who have functional or anatomic asplenia (e.g., sickle cell disease or splenectomy) also should be vaccinated.

• Persons two years of age or older who are living in environments or social settings in which the risk for invasive pneumococcal disease or its complications is increased (e.g., Alaskan Natives and certain American Indian populations) should be vaccinated. In addition, because of recently reported outbreaks of pneumococcal disease, vaccination status should be assessed for residents of nursing homes and other long-term-care facilities.

  Available data do not support routine pneumococcal vaccination of healthy children attending day care facilities. Recurrent upper respiratory tract diseases, including otitis media and sinusitis, are not specific indications for pneumococcal vaccine.

  Persons who have conditions associated with decreased immunologic function that increase the risk for severe pneumococcal disease or its complications should be vaccinated. Although the vaccine is not as effective for immunocompromised patients as it is for immunocompetent persons, the potential benefits and safety of the vaccine justify its use.
  

• Immunocompromised persons aged greater than or equal to two years, including persons with HIV infection, leukemia, lymphoma, Hodgkins disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome, or other conditions associated with immunosuppression (e.g., organ or bone marrow transplantation); and persons receiving immunosuppressive chemotherapy, including long-term systemic corticosteroids. If earlier vaccination status is unknown, immunocompromised persons should be administered pneumococcal vaccine.

• Persons with asymptomatic or symptomatic HIV infection should be vaccinated as soon as possible after their diagnosis is confirmed.
  

• All infants up to age 23 months.
• Children aged 24-59 months who are at high risk for invasive pneumococcal infection. This recommendation applies to the following groups:
  

  Children with SCD and other sickle cell hemoglobinopathies, children who are functionally or anatomically asplenic;

  Children with HIV infection;

  Children who have chronic disease, including chronic cardiac and pulmonary disease (excluding asthma), diabetes mellitus, or CSF leak; and,

  Children with immunocompromising conditions.

  
  

• Children aged 24-35 months;
• Children of Alaska Native or American Indian descent;
• Children of African-American descent;
• Children who attend group day care centers;
• Children who are socially or economically disadvantaged; and,
• Children with frequent/recurrent otitis media.
  

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

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: (90281, 90283, 90371, 90375-90376, 90378, 90379, 90389, 90396, 90636, 90645-90648, 90657-90659, 90669, 90675-90676, 90700-90709, 90712, 90713, 90716, 90718-90721, 90732-90733, 90740-90748, J1460-J1560, J1561, J1563, J1565, and J1670.)

NOTE:

Effective October 15, 1999, the FDA has withdrawn the rotavirus vaccine from the market because of incidents of intussusception after vaccination. Therefore, the rotavirus vaccine (90680) is no longer considered medically appropriate treatment and will be denied as noncovered and nonbillable to the member.

Other than those specific childhood immunizations listed above, immunizations are covered only under specific Highmark/Pennsylvania Blue Shield contracts. When a claim is received for an immunization, it should be processed for payment under the appropriate procedure code. Immunization is acceptable for the following diseases:

Cholera
Diphtheria
Hepatitis A
Influenza
Mumps
Pertussis (whooping cough)
Pneumonia
Plague
Polio
Rubella
Rubeola (measles)
Tetanus
Tuberculosis (BCG)
Typhoid fever
Varicella (chicken pox vaccine-90716)
Varicella-Zoster (immunoglobulin-90396)
Yellow Fever

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.

Rh Immune Globulin is an accepted immunization procedure for mothers who have Rh negative blood type.

NOTE:

In addition to the procedure codes listed under the childhood immunizations, the following codes are applicable to the other immunizations: (90585, 90632-90634, 90636, 90690-90692, 90717, 90725, 90727, 90735, 90740, 90746, 90747, and 90749).

NOTE:

A separate administration fee can be reported with each separately administered immunization. Codes G0008-G0010, G0190-G0191, and 90471-90472 should be reported as appropriate in addition to immunization procedures 90281, 90283, 90371-90379, 90389, 90396, 90585, 90632-90634, 90645-90648, 90657-90659, 90669, 90675-90676, 90691-90692, 90700-90709, 90713-90721, 90725-90744, 90746-90749, J1460-J1563, J1565, and J1670. (This applies to all patients, regardless of age, who have coverage for immunizations.) If codes G0008-G0010, G0190-G0191, 90471-90472 are reported with codes other than those specified or, if they are reported as the sole service they will be denied as noncovered and they are nonbillable by a participating/preferred provider.

The information outlined above on childhood immunizations does not apply to the Federal Employee Program.

Meningococcal vaccine (90733) is eligible under other medical benefits for members who have been exposed to the disease, or are considered high risk for contracting the disease.

Managed Care

Immunizations administered for foreign travel are not covered.

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 Cross Blue Shield may pay for FDA-approved pneumococcal vaccines
10/2000, Blue Cross Blue Shield issues new coverage guidelines for Prevnar™
04/2001, Blue Cross Blue Shield to follow ACIP guidelines for Prevnar™
08/2001, New combination vaccine for hepatitis

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