Highmark Commercial Medical Policy - Pennsylvania
Medical Policy: I-8-069
Topic: Immunizations
Section: Injections
Effective Date: July 1, 2018
Issue Date: July 2, 2018
Last Reviewed: May 2017

Patient Protection and Affordable Care Act, as amended (PPACA) (Enacted 3/23/2010)
Comprehensive Guidelines supported by the Health Resources and Services Administration Bright Futures™American Academy of Pediatrics

Childhood Immunization Insurance Act (Act 35 of 1992)
Childhood Immunizations (Effective 11/21/1992)
Pennsylvania's Act 83 of 2002 (Effective 08/28/2002)

Refer to the current year’s Preventive Schedule for guidelines on the Provider Resource Center for when and how often the following immunizations are recommended. This schedule is a reference tool for planning preventive care, and lists items/services required under the Patient Protection and Affordable Care Act of 2010 (PPACA), as amended. It is reviewed and updated periodically based on the advice of the U.S. Preventive Services Task Force, laws and regulations and updates to clinical guidelines established by national medical organizations. Accordingly, the content of this schedule is subject to change. Specific needs for preventive immunizations may vary according to member’s personal risk factors.

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.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

The following mandated immunizations are covered for the insured or the insured spouse who are greater than or equal to 21 years of age, or a dependent child in accordance with the age limits of the individual contracts:

Procedure Codes
90375, 90376, 90620, 90621, 90630, 90632, 90633, 90634, 90636, 90644, 90647, 90648, 90649, 90651, 90654, 90655, 90656, 90657, 90658, 90661, 90670, 90672, 90673, 90674, 90680, 90681, 90682, 90685, 90686, 90687, 90688, 90696, 90698, 90700, 90702, 90703, 90707, 90710, 90713, 90714, 90715, 90716, 90723, 90732, 90733, 90734, 90740, 90743, 90744, 90745, 90746, 90747, 90748, 90756, J1560, Q2034, Q2035, Q2036, Q2037, Q2038, Q2039


Other Non-Mandated 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:

Immunizations or injections for diseases other than those listed above are not eligible for payment. Immunizations must be FDA approved to be eligible for payment. 

Procedure Codes
90585, 90625, 90630, 90632, 90647, 90648, 90662, 90670, 90673, 90674, 90675, 90676, 90688, 90690, 90691, 90713, 90716, 90717, 90732, 90736, 90738, 90749, 90750


The cholera vaccine (procedure code 90625) is not FDA approved and, therefore, is non-covered. 

Procedure Codes
90625


Note: Dosage recommendations per the FDA label. 

Refer to medical policy I-20 Immune Prophylaxis for Respiratory Syncytial Virus (RSV) for additional information.

Refer to medical policy I-14 Immune Globulin Therapy for additional information.

Refer to medical policy V-37 Autism Spectrum Disorders for additional information.

NOTE:
Codes 90460-90461, 90471-90474, and 90673 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 90460-90461, 90471-90474, and 90673 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 will also be subject to coverage limitations specified within the individual member's contract.


The policy position applies to all commercial lines of business


Denial Statements

A network provider can bill the member for the non-covered service.

Links




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.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer: If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

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.