Medical_Policy

Highmark Medical Policy Bulletin

Section:	Injections
Number:	I-8
Topic:	Immunizations
Effective Date:	May 5, 2003
Issued Date:	May 5, 2003
Date Last Reviewed:	03/2003

General Policy Guidelines

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

The following mandated immunizations are covered for individuals who are up to and including 20 years of age:

Diphtheria
Hemophilus B (HIB)
Hepatitus A
Hepatitis B
Influenza
Meningococcal
Mumps
Pertussis (whooping cough)
Pneumonia
Pneumoccal conjugate, 7-valent (e.g., Prevnar)(90669, S0195)
Pneumoccal polysaccharide, 23-valent (90732)
Polio
Respiratory Syncytial Virus (RSV)
Rubella
Rubeola (measles)
Tetanus
Varicella (chicken pox vaccine-90716)

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

Also, gamma globulin (codes 90281, J1460-J1560) and immune globulin (codes 90283, 90379, 90389, 90396, J1563, J1564, J1565, J1670) are covered as immunizations.

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.

Pediatrix™ (90723), a combination of the DtaP (Diptheria 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.

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, 90632, 90633, 90634, 90636, 90645-90648, 90657-90659, 90669, 90675-90676, 90700-90708, 90712, 90713, 90716, 90718-90721, 90732-90733, 90740-90748, J1460-J1560, J1563, J1564, J1565, J1670, Q3021, and S0195.)

NOTE:: Effective October 15, 1999, the FDA has withdrawn the rotavirus vaccine from the market because of incidents of intussusception after vaccination.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 not covered. A participating, preferred, or network provider cannot bill the member for the denied service.

OTHER NON-MANDATED IMMUNIZATIONS

Other than those specific childhood immunizations listed above, immunizations are covered only under specific 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
Meningococcal
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

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

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, 90749, Q3022, and Q3023).

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 G0008-G0010, and 90471-90472 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 90471-90472, G0008-G0010 are reported as the sole service they will be eligible for payment.

NOTE:: 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

90281	90283	90371	90375	90376	90378
90379	90389	90396	90471	90472	90585
90632	90633	90634	90636	90645	90646
90647	90648	90657	90658	90659	90669
90675	90676	90680	90690	90691	90692
90700	90701	90702	90703	90704	90705
90706	90707	90708	90712	90713	90716
90717	90718	90719	90720	90721	90725
90727	90732	90733	90735	90740	90743
90744	90746	90747	90748	90749	G0008
G0009	G0010	J1460	J1470	J1480	J1490
J1500	J1510	J1520	J1530	J1540	J1550
J1560	J1563	J1564	J1565	J1570	S0195

Traditional (UCR/Fee Schedule) Guidelines

Refer to General Policy Guidelines

FEP Guidelines

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.

Also refer to General Policy Guidelines

Comprehensive/Wraparound/PPO Guidelines

Under the Western Region PreferredBlue PPO product, effective June 1, 2002, Highmark will reimburse KHPW network physicians for their office visits and administration (90471-90472) fees only. The preparation Synagis will be billed to Highmark by selected pharmacy vendors.

Also refer to General Policy Guidelines

Managed Care (HMO/POS) Guidelines

Immunizations administered for foreign travel are not covered.

Under the Western Region HMO and POS products, including DirectBlue and CommunityBlue Direct, effective June 1, 2002, Highmark will reimburse KHPW network physicians for their office visits and administration (90471-90472) fees only. The preparation Synagis will be billed to Highmark by selected pharmacy vendors.

Also refer to General Policy Guidelines

Publications

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

References

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

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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

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