CAM 109

Preventive Services for Non Grandfathered (PPACA) Plans: Immunizations

Category:Other   Last Reviewed:October 2018
Department(s):Medical Affairs   Next Review:October 2019
Original Date:October 2015    

Description
The U.S. Patient Protection and Affordable Care Act (PPACA) was passed by Congress and signed into law by the president in March 2010. The preventive services component of the law became effective Sept. 23, 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force (USPSTF).

Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.

Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention. Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds. Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination. Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.

Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, coinsurance or copay) by Health Plans for appropriate preventive care services provided by an in-network provider. If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, coinsurance or copay may be applied.

Services are typically included as part of a normal wellness visit; the appropriate office visit code should be used. Evaluation and Management codes for preventive services 99381-99397 will always be considered preventive. CPT Codes 99401-99404, when used to designate a preventive service, must have the applicable wellness/preventive diagnosis code as the primary reason for the visit.

When the primary purpose of the service is the delivery of an evidence-based service in accordance with a U.S. Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.

TRAVEL IMMUNIZATIONS ADDITIONAL INFORMATION:

Immunizations that are specific to travel (e.g., typhoid, yellow fever, cholera, plague and Japanese encephalitis virus) are not required by PPACA and are excluded from coverage.  

NOTE: THIS POLICY APPLIES ONLY TO NON-GRANDFATHERED PLANS.  

Background
The ACIP develops recommendations on how to use vaccines to control disease in the United States. The recommendations include the age(s) when the vaccines should be given, the number of doses needed, the amount of time between doses and precautions and contraindications.

Professional organizations that work with the ACIP to develop the annual childhood and adult schedules include the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG) and the American College of Physicians (ACP).

The Committee's recommendations are forwarded to CDC’s director for approval. Once the ACIP recommendations have been reviewed and approved by the CDC director and the U.S. Department of Health and Human Services, they are published in CDC’s Morbidity and Mortality Weekly Report (MMWR). The MMWR publication represents the final and official CDC recommendations for immunization of the U.S. population.

Each year, the Advisory Committee on Immunization Practices (ACIP) publishes immunization schedules for persons age birth through 18 years. These schedules summarize recommendations for routine vaccines for children age 18 years and younger.

The recommended immunization schedules for persons age birth through 18 years and the catch-up immunization schedule have been approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics, the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists. 

Policy
The following immunizations are considered MEDICALLY NECESSARY when given in accordance with ACIP guidelines:

An immunization is considered NOT MEDICALLY NECESSARY if it does not meet Vaccine Policy requirements for FDA labeling (including age and/or gender limitations) and if it does not have definitive ACIP recommendations published in the CDC’s Morbidity and Mortality Weekly Report (MMWR).

Age Group column: This column is provided for informational use only. For purposes of this document: Adult means age 18 years and up; pediatric means age 0-18 years.

Benefit Limits column: Benefit Limits in bold text are from FDA labeling and ACIP recommendations. Codes that indicate “For applicable age, see code description” are limited to the age(s) listed in the code description.

PREVENTIVE IMMUNIZATIONS

These codes do not have a diagnosis code requirement for preventive benefits to apply. 

PREVENTIVE IMMUNIZATIONS

These codes do not have a diagnosis code requirement for preventive benefits to apply.

Category: Code(s): Description: Age Group: Benefit Limits: Age/Other

Immunization Administration

Preventive when included as part of a preventive immunization.

90460 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 Pediatric For applicable age see code description
90461 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) Pediatric For applicable age see code description
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous or intramuscular injections); one vaccine (single or combination vaccine/toxoid) Both
90472 Immunization administration (includes percutaneous, intradermal, subcutaneous or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) Both
90473 Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid) Both
90474 Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) Both
G0008 Administration of influenza virus vaccine Both
G0009 Administration of pneumococcal vaccine Both
G0010 Administration of hepatitis B vaccine Both
Meningococcal 90620 Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B (MenB-4C), 2 dose schedule, for intramuscular use Both

Benefit Limit:

Age 10 and up

90621 Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB-FHbp), 2 or 3 dose schedule, for intramuscular use Both

Benefit Limit:  

Age 10 and up

90644 Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus influenzae b vaccine (Hib-MenCY), 4-dose schedule, when administered to children 2-15 months of age, for intramuscular use Pediatric For applicable age see code description.
90733 Meningococcal polysaccharide vaccine, serogroups A, C, Y, W-135, quadrivalent (MPSV4) for subcutaneous use Both  
90734 Meningococcal conjugate vaccine, serogroups A, C, Y and W-135, quadrivalent (MenACWY), for intramuscular use Both  
Hepatitis A 90632 Hepatitis A vaccine (HepA), adult dosage, for intramuscular use Adult For applicable age see code description.
90633 Hepatitis A vaccine (HepA), pediatric/ adolescent dosage-2-dose schedule, for intramuscular use Pediatric For applicable age see code description.
90634 Hepatitis A vaccine (HepA), pediatric/adolescent dosage-3-dose schedule, for intramuscular use Pediatric For applicable age see code description.
90636 Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use Adult For applicable age see code description.
Haemophilus influenza b (Hib): 90645 Hemophilus influenza b vaccine (Hib), HbOC conjugate (4-dose schedule), for intramuscular use Both -
90646 Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use Both -
90647 Haemophilus influenzae b vaccine (Hib), PRP-OMP conjugate, 3-dose schedule, for intramuscular use Both -
90648 Haemophilus influenzae b vaccine (Hib), PRP-T conjugate, 4-dose schedule, for intramuscular use Both -
Human Papilloma Virus (HPV) 90649

Human Papilloma virus vaccine, types 6, 11, 16, 18, quadrivalent (HPV4), 3-dose schedule, for intramuscular use

Both Benefit Limit: Ages 9-26yrs. Ends on 27th birthday.
90650 Human Papilloma virus vaccine, types 16, 18, bivalent (HPV2), 3-dose schedule, for intramuscular use Both

Benefit Limit: Females, ages 9-26yrs. Ends on 27th birthday. This vaccine is not covered for males.

90651 Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use Both Benefit Limit: Ages 9-26yrs. Ends on 27th birthday.

Seasonal Influenza (‘flu’)

Note: Additional new seasonal flu immunization codes that are recently FDA-approved, but are not listed here, may be eligible for preventive benefits as of the FDA approval date.
90630 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use Both -
90653 Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use Both -
90654 Influenza virus vaccine, trivalent (IIV3), split virus, preservative-free, for intradermal use Adult Benefit Limit: 18 years – 64 years. Ends on 65th birthday.
90655 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use Pediatric For applicable age see code description.
90655 (effective 1/1/2017)  Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for intramuscular use  Both  
90656 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use Both For applicable age see code description.
90656 (effective 1/1/2017)  Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use  Both   
90657 Influenza virus vaccine, trivalent(IIV3), split virus, when administered to children 6-35 months of age, for intramuscular use Pediatric For applicable age see code description.
90657 (effective 1/1/2017)  Influenza virus vaccine, trivalent(IIV3), split virus, 0.25 mL dosage, for intramuscular use  Both   
90658 Influenza virus vaccine, trivalent (IIV3), split virus, when administered to individuals 3 years of age and older, for intramuscular use Both For applicable age see code description.
90658 (effective 1/1/2017)  Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use  Both   
90660 Influenza virus vaccine, trivalent, live (LAIV3), for intranasal use Both Benefit Limit: Ages 2 – 49 Years. Ends on 50th birthday
90661 Influenza virus vaccine (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use Adult

Benefit Limit: Ages 18 years and up

90661 (effective 1/1/2017)  Influenza virus vaccine trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use  Adult 

 

90662 Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use Adult

Benefit Limit: Ages 65 years and up

90664 Influenza virus vaccine, live (LAIV), pandemic formulation, for intranasal use Both Benefit Limit: Ages 2 – 49 Years. Ends on 50th birthday.
90666 Influenza virus vaccine (IIV), pandemic formulation, split virus, preservative free, for intramuscular use  Both -
90667  Influenza virus vaccine (IIV), pandemic formulation, split virus, adjuvanted, for intramuscular use Both -
90668  Influenza virus vaccine (IIV), pandemic formulation, split virus, for intramuscular use Both -
90672 Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use Both Benefit Limit: Ages 2 – 49 Years. Ends on 50th birthday.
90673 Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use  Adult Benefit Limit: Ages 18 – 49 Years. Ends on 50th birthday.
90674 (effective 1/1/2017)  Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subnit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use   Adult   
90682 (effective 1/01/2017)  Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use  Adult   
90685 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use  Pediatric For applicable age see code description.
90685 (effective 1/1/2017)  Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for intramuscular use  Pediatric   
90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use  Both For applicable age see code description.
90686 (effective 1/1/2017)  Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use  Both   
90687 Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to children 6-35 months of age, for intramuscular use  Pediatric For applicable age see code description.
90687 (effective 1/1/2017)  Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL dosage, for intramuscular use  Pediatric   
90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to individuals 3 years of age and older, for intramuscular use Both For applicable age see code description.
90688 (effective 1/1/2017)  Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage, for intramuscular use  Both   
90689 (effective 01/01/2019) 

Influenza virus vaccine, quadrivalent (IIV4), inactivated, adjuvanted, preservative free, 0.25 mL dosage, for intramuscular use 

Both   
90756 (effective 1/1/2018)  

Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use TOS Code: V

Adult   
Q2034 Influenza virus vaccine, split virus, for intramuscular use (Agriflu)  Adult

Benefit Limit: Ages 18 years and up

Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (AFLURIA)  Both For applicable age see code description.
Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLULAVAL)  Both For applicable age see code description.
Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLUVIRIN)  Both For applicable age see code description.
Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)  Both For applicable age see code description.
Q2039 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified)  Both For applicable age see code description.
Pneumococcal polysaccharide (PPSV23)  90732   Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use Both  For applicable age see code description. 
Pneumococcal conjugate  90669  Pneumococcal conjugate vaccine, 7 valent (PCV7), for intramuscular use  Pediatric   Benefit Limit: Age 0-5 yrs. Ends on 6th birthday 
  90670   Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use Both   -
  S0195   Pneumococcal conjugate vaccine, polyvalent, intramuscular, for children from five years to nine years of age who have not previously received the vaccine Pediatric    For applicable age see code description. 
Rotavirus  90680 

Rotavirus vaccine, pentavalent (RV5), 3-dose schedule, live, for oral use 

Pediatric 

Do not begin series in infants older than age 14wks 6 days.

  • Intervals between doses may be as short as 4wks.
  • If prior vaccination included use of different or unknown brand(s), a total of 3 doses should be given.
  90681

Rotavirus vaccine, human, attenuated (RV1), 2-dose schedule, live, for oral use 

Pediatric

Do not begin series in infants older than age 14wks 6 days.

  • Intervals between doses may be as short as 4wks.
  • If prior vaccination included use of different or unknown brand(s), a total of 3 doses should be given.
Diphtheria, tetanus toxoids, acellular pertussis and polio inactive (DTap-IPV)  90696  Diphtheria, tetanus toxoids, acellular pertussis vaccine and inactivated poliovirus vaccine (DTaP-IPV), when administered to children 4 through 6 years of age, for intramuscular use  Pediatric  For applicable age see code description. 
Diphtheria, tetanus toxoids, acellular pertussis, haemophilus influenza B and polio inactive (DTap-IPV/Hib)  90698  Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenzae Type b and inactivated poliovirus vaccine (DTaP – IPV/Hib), for intramuscular use  Both 
Diphtheria, tetanus, acellular pertussis (DTap)  90700  Diphtheria, tetanus toxoids and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use  Pediatric  For applicable age see code description 
Diphtheria and tetanus (DT) 90702  Diphtheria and tetanus toxoids adsorbed (DT) when administered to individuals younger than 7 years, for intramuscular use  Pediatric  For applicable age see code description  

Tentanus

 
90703  Tetanus toxoid adsorbed, for intramuscular use  Both 
Measles, Mumps, Rubella (MMR) combination or individual       90704  Mumps virus vaccine, live, for subcutaneous use  Both  
90705 Measles virus vaccine, live, for subcutaneous use  Both  
90706 Rubella virus vaccine, live, for subcutaneous use  Both  
90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use  Both  
90708 Measles and rubella virus vaccine, live, for subcutaneous use  Both  
90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use  Both  

Polio (IPV) 

90713  Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use  Both    
Tetanus and diphtheria (Td)  90714  Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for intramuscular use  Both  For applicable age see code description. 
Tetanus, diphtheria toxoids and acellular pertussis (Tdap)  90715  Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use  Both  For applicable age see code description.  

Varicella (VAR) (‘chicken pox’) 

90716 

Varicella virus vaccine (VAR), live, for subcutaneous use  Both  
Diphtheria  90719  Diphtheria toxoid, for intramuscular use  Both   
Diptheria, tetanus and whole pertussis and Haemophilus influenza B (DTwP-Hib)  90720  Diphtheria, tetanus toxoids and whole cell pertussis vaccine and Haemophilus influenzae b vaccine (DTwP-Hib), for intramuscular use  Both    
Diptheria, tetanus and acellular pertussis and Haemophilus influenza B (DTaP-Hib)  90721  Diphtheria, tetanus toxoids and acellular pertussis vaccine and Haemophilus influenza b vaccine (DTaP/Hib), for intramuscular use  Both     
Diptheria, tetanus and acellular pertussis, hep B and polio inactive (DTaP-HepB-IPV)  90723  Diphtheria, tetanus toxoids, acellular pertussis vaccine, hepatitis B and inactivated poliovirus vaccine (DTaP-HepB-IPV), for intramuscular use  Both  Benefit Limit: Ages 0-6yrs. Ends on 7th birthday. 
Zoster/Shingles (HZV)  90736  Zoster (shingles) vaccine (HZV), live, for subcutaneous injection  Adult  Benefit Limit: Age 50 years and up. 
  90750 (effective 1/01/2017)  ZOSTER (SHINGLES) VACCINE (HZV), RECOMBINANT, SUB-UNIT, ADJUVANTED, FOR INTRAMUSCULAR INJECTION  Adult   
Hepatitis B       90740  Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3-dose schedule, for intramuscular use  Both  
90743  Hepatitis B vaccine (HepB), adolescent, 2-dose schedule, for intramuscular use  Pediatric (adolescent only)  For applicable age see code description. 
90744  Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3-dose schedule, for intramuscular use  Pediatric  For applicable age see code description. 
90746  Hepatitis B vaccine (HepB), adult dosage, 3-dose schedule, for intramuscular use  Adult  For applicable age see code description.  
90747  Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 4-dose schedule, for intramuscular use  Both   
90748  Hepatitis B and Haemophilus influenza b vaccine (Hib-HepB), for intramuscular use  Both    

References

  1. http://www.cdc.gov/vaccines/acip/recs/index.html 
  2. http://www.cdc.gov/vaccines/hcp/acip-recs/index.html 
  3. http://www.cdc.gov/vaccines/schedules/hcp/index.html 
  4. http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf 
  5. http://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html 
  6. http://www2a.cdc.gov/vaccines/iis/iisstandards/vaccines.asp?rpt=cpt
  7. http://www.cdc.gov/flu/protect/vaccine/vaccines.htm

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2015 Forward     

12/21/2019 

Updating with 2019 codes.  

10/29/2018 

Annual review, no change to policy intent. 

11/29/2017 

Updating policy with 2018 coding. No other changes. 

11/15/2017 

Annual review, no change to policy intent. Adding CPT codes 90756 & 90682 which are both new flu vaccine codes for 2018. 

08/24/2017 

Adding Code 90756 to coding section. No change to policy intent. 

03/01/2017 

Updated coding. 

10/27/2016 

Annual review, no change to policy intent. 

08/03/2016 

Updated CPT codes to be effective 1/1/2017. 

09/01/2015

NEW POLICY


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