CAM 015

Influenza Vaccine

Category:Medicine   Last Reviewed:September 2019
Department(s):Medical Affairs   Next Review:September 2020
Original Date:October 2008    

Description:
Influenza viruses ("the flu") infect the respiratory tract. Symptoms include fever, cough, sore throat, runny or stuffy nose, headache, muscle aches and extreme fatigue. The flu season usually peaks between late December and early March. The optimal time to be vaccinated against influenza is from October through mid-November.

Policy:
Standard or preservative-free injectable influenza vaccine is a MEDICALLY NECESSARY preventive service for members when influenza immunization is recommended by the Centers for Disease Control (CDC) Advisory Committee. The current CDC recommendation is that all persons aged 6 months or older receive influenza vaccine.

NOTE: Some plans exclude preventive services. Please check benefit plan descriptions for details on coverage.

Intranasally administered influenza vaccine is considered a MEDICALLY NECESSARY alternative to injectable influenza vaccine for immunocompetent healthy persons 2 to 49 years of age as recommended by the CDC's Advisory Committee on Immunization Practices (ACIP). 

Rationale:

Timing of Vaccination

  • In general, health care providers should begin offering vaccination soon after vaccine becomes available, and, if possible, by October.
  • All children ages 6 months to 8 years who are recommended for two doses should receive their first dose as soon as possible after vaccine becomes available. These children should receive the second dose ≥ four weeks later.

Persons at Risk for Medical Complications Due to Influenza

Vaccination to prevent influenza is particularly important for persons who are at increased risk for severe complications from influenza, or at higher risk for influenza-related outpatient, emergency department or hospital visits. When vaccine supply is limited, vaccination efforts should focus on delivering vaccination to the following persons (no hierarchy is implied by order of listing):

  • All children aged 6 months through 59 months
  • All persons aged ≥ 50 years
  • Adults and children who have chronic pulmonary (including asthma) or cardiovascular (except isolated hypertension), renal, hepatic, neurological, hematologic or metabolic disorders (including diabetes mellitus)
  • Persons who have immunosuppression (including immunosuppression caused by medications or by HIV infection)
  • Women who are or will be pregnant during the influenza season
  • Children and adolescents (aged 6 months-18 years) who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye’s syndrome after influenza virus infection
  • Residents of nursing homes and other long-term care facilities
  • American Indians/Alaska Natives
  • Persons who are morbidly obese (BMI ≥ 40)

Persons Who Live With or Care for Persons at Higher Risk for Influenza-Related Complications

All persons aged ≥ 6 months should be vaccinated annually. Continued emphasis should be placed on vaccination of persons who live with or care for persons at higher risk for influenza-related complications. When vaccine supply is limited, vaccination efforts should focus on delivering vaccination to persons at higher risk for influenza-related complications listed above, as well as these persons:

  • Health care personnel (HCP)
  • Household contacts (including children) and caregivers of children aged ≤ 59 months (i.e., aged <5 years) and adults aged ≥ 50 years, with particular emphasis on vaccinating contacts of children aged <6 months
  • Household contacts (including children) and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza

HCP and persons who are contacts of persons in these groups and who are not contacts of severely immunocompromised persons (those living in a protective environment) may receive any influenza vaccine that is otherwise indicated. People who care for the severely immunocompromised should receive either IIV or RIV3.

Influenza Vaccination for Pregnant Women

  • Women who are or will be pregnant during influenza season should receive IIV. Live attenuated influenza vaccine (LAIV) is not recommended for use during pregnancy.
  • Postpartum women can receive either LAIV or IIV.
  • Pregnant and postpartum women do not need to avoid contact with persons recently vaccinated with LAIV.

Concurrent Administration of Influenza Vaccine With Other Vaccines

  • Inactivated vaccines do not interfere with the immune response to other inactivated vaccines or to live vaccines.
  • Inactivated or live vaccines can be administered simultaneously with LAIV.
  • However, after administration of a live vaccine,at least 4 weeks should pass before another live vaccine is administered.

Concurrent Administration of Influenza Vaccine With Other Vaccines

  • Inactivated vaccines do not interfere with the immune response to other inactivated vaccines or to live vaccines.
  • Inactivated or live vaccines can be administered simultaneously with LAIV.
  • However, after administration of a live vaccine, at least 4 weeks should pass before another live vaccine is administered.

TABLE 1. Influenza Vaccines — United States, 2016–17 Influenza Season*

Trade name

Manufacturer

Presentation

 

Age indications

 

Mercury (from thimerosal) μg/0.5 mL

Latex 

Route

Inactivated influenza vaccine, quadrivalent (IIV4), standard dose

Fluarix Quadrivalent

GlaxoSmithKline

0.5 mL single-dose prefilled syringe

≥ 3 yrs. 

NR

No 

IM§

FluLaval Quadrivalent

ID Biomedical Corporation of Quebec (distributed by GlaxoSmithKline)

5.0 mL multi-dose vial

≥ 3 yrs. 

NR

No 

IM

 

 

 5.0 mL multi-dose vial

≥ 3 yrs. 

 

<25 

 

 

Fluzone Quadrivalent 

 

 

 

 

 

Sanofi Pasteur

 

 

 

 

0.25 mL single-dose prefilled syringe

6 through 35 mos. 

NR

No 

IM

0.5 mL single-dose prefilled syringe

≥3 6 mos. 

NR

No 

IM

0.5 mL single-dose syringe 

≥ 36 mos. 

NR

No 

IM 

5.0 mL multi-dose vial

≥6 mos. 

25

No 

IM

Fluzone Intradermal

Quadrivalent

Sanofi Pasteur

0.1 mL single-dose prefilled microinjection system

18 through 64 yrs 

NR

No 

ID**

Inactivated influenza vaccine, quadrivalent, cell culture-based (ccIIV4), standard dose 

Flucelvax Quadrivalent 

Seqirus 

0.5 mL single-dose prefilled syringe 

≥ 4 yrs

NR 

No 

IM 

Inactivated Influenza Vaccine, trivalent (IIV3), standard dose

Afluria

 

Seqirus

 

0.5 mL single-dose prefilled syringe

≥ 9 yrs†† 

NR

No 

IM

5.0 mL multi-dose vial

≥ 9 yrs†† (needle and syringe) 18 through 64 years (jet injector) 

24.5

No 

IM 

Fluvirin

 

Seqirus

 

0.5 mL single-dose prefilled syringe

≥ 4 yrs 

≤ 1 

Yes§§ 

IM 

5.0 mL multi-dose vial

 

≥4  yrs  

 25

No 

IM 

Adjuvanted Inactivated Influenza Vaccine, trivalent (aIIV3), standard dose

Fluad

Seqirus

0.5 mL single-dose prefilled syringe 

≥ 65 yrs 

NR

Yes§§ 

IM  

Inactivated Influenza Vaccine, trivalent (IIV3), high dose

Fluzone High-Dose

Sanofi Pasteur 

0.5 mL single-dose prefilled syringe 

≥ 65 yrs 

NR

No 

IM   

Recombinant Influenza Vaccine, trivalent (RIV3)*** 

Flublok 

Protein Sciences 

0.5 mL single-dose vial 

≥ 18 yrs 

NR

No 

IM  

Live attenuated influenza vaccine, quadrivalent (LAIV4)†††

FluMist Quadrivalent

MedImmune 

0.2 mL single-dose prefilled intranasal sprayer 

2 through 49 yrs 

NR 

No 

NAS 

Abbreviations: ACIP = Advisory Committee on Immunization Practices; ID = intradermal; IM = intramuscular; NAS= intranasal; NR=not relevant (does not contain thimerosal).

*Immunization providers should check Food and Drug Administration–approved prescribing information for 2016–17 influenza vaccines for the most complete and updated information, including (but not limited to) indications, contraindications, warnings and precautions. Package inserts for U.S.-licensed vaccines are available at http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm093833.htm. Availability of specific products and presentations might change and differ from what is described in this table.
Standard dose intramuscular IIVs contain 15 µg of each vaccine HA antigen (45 µg total for trivalents and 60 µg total for quadrivalents) per 0.5mL dose.
§For adults and older children, the recommended site for intramuscular influenza vaccination is the deltoid muscle. The preferred site for infants and young children is the anterolateral aspect of the thigh. Specific guidance regarding site and needle length for intramuscular administration may be found in the ACIP General Recommendations on Immunization, available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm.
Quadrivalent inactivated influenza vaccine, intradermal: a 0.1-mL dose contains 9 µg of each vaccine HA antigen (36μg total).
**The preferred injection site is over the deltoid muscle. Fluzone Intradermal Quadrivalent is administered using the delivery system included with the vaccine.

††Age indication per package insert is ≥ 5 years; however, ACIP recommends that Afluria not be used in children aged 6 months through 8 years because of increased risk for febrile reactions noted in this age group with Seqirus’ 2010 Southern Hemisphere IIV3. If no other age-appropriate, licensed inactivated seasonal influenza vaccine is available for a child aged 5 through 8 years who has a medical condition that increases the child's risk for influenza complications, Afluria can be used; however, providers should discuss with the parents or caregivers the benefits and risks of influenza vaccination with Afluria before administering this vaccine. Afluria may be used in persons aged ≥ 9 years. Afluria is licensed for administration by jet injector for persons aged 18 through 64 years only.
§§Syringe tip cap might contain natural rubber latex.
¶¶High-dose IIV3 contains 60 μg of each vaccine antigen (180 μg total) per 0.5mL dose.
***RIV3 contains 45 μg of each vaccine HA antigen (135 μg total) per 0.5mL dose.
†††ACIP recommends that Flumist (LAIV4) not be used during the 2016–17 season.

TABLE 2. Contraindications and precautions to the use of influenza vaccines — United States, 2016–17 influenza season* 

VaccineContraindications    Precautions
IIV History of severe allergic reaction to any component of the vaccine or after previous dose of any influenza vaccine     Moderate to severe illness with or without fever
    History of Guillain-Barré syndrome within 6 weeks of receipt of influenza vaccine
RIV History of severe allergic reaction to any component of the vaccine     Moderate to severe illness with or without fever
    History of Guillain-Barré syndrome within 6 weeks of receipt of influenza vaccine
LAIV     For the 2016–17 season, ACIP recommends that LAIV not be used. Content below is provided for information.
  History of severe allergic reaction to any component of the vaccine† or after a previous dose of any influenza vaccine
Concomitant aspirin or salicylate-containing therapy in children and adolescents
Children aged 2 through 4 years who have received a diagnosis of asthma or whose parents or caregivers report that a health care provider has told them during the preceding 12 months that their child had wheezing or asthma or whose medical record indicates a wheezing episode has occurred during the preceding 12 months
Children and adults who have immunosuppression (including immunosuppression caused by medications or by HIV)
Close contacts and caregivers of severely immunosuppressed persons who require a protected environment
Pregnancy
Receipt of influenza antiviral medication within the previous 48 hours
    Moderate to severe illness with or without fever
    History of Guillain-Barré syndrome within 6 weeks of receipt of influenza vaccine
    Asthma in persons aged ≥ 5 years
    Other underlying medical conditions that might predispose to complications after wild-type influenza infection (e.g., chronic pulmonary, cardiovascular [except isolated hypertension], renal, hepatic, neurologic, hematologic or metabolic disorders (including diabetes mellitus)

Abbreviations: ACIP = Advisory Committee on Immunization Practices; IIV = Inactivated Influenza Vaccine; LAIV = Live-Attenuated Influenza Vaccine; RIV = Recombinant Influenza Vaccine.
* Immunization providers should check Food and Drug Administration–approved prescribing information for 2016–17 influenza vaccines for the most complete and updated information, including (but not limited to) indications, contraindications and precautions. Package inserts for US-licensed vaccines are available at http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm093833.htm.
History of severe allergic reaction (e.g., anaphylaxis) to egg is a labeled contraindication to the use of IIV and LAIV. However, ACIP recommends that any licensed, recommended and appropriate IIV or RIV may be administered to persons with egg allergy of any severity (see Influenza Vaccination of Persons with a History of Egg Allergy).

FIGURE. Influenza vaccine dosing algorithm for children aged 6 months through 8 years — Advisory Committee on Immunization Practices, United States, 2016–17 influenza season 

	The figure depicts the influenza vaccine dosing algorithm for children aged 6 months through 8 years as recommended by the Advisory Committee on Immunization Practices for the 2016–17 influenza season in the United States. If the child received two or more total doses of trivalent or quadrivalent influenza vaccine before July 1, 2016 (doses need not have been received during the same season or consecutive seasons), then the child should receive one dose of 2016–17 influenza vaccine. If the child did not receive two or more total doses of trivalent or quadrivalent influenza vaccine before July 1, 2016 or if it is not known whether the child received two doses, then the child should receive two doses of 2016–17 influenza vaccine, administered four or more weeks apart.

References:

  1. Bauchner H. Journal Watch Pediatrics and Adolescents. Flu Shots or Intranasal Flu Vaccine for Children? Reviewed Oct 2008.
  2. Huffman G. American Family Practice. Effectiveness of Intranasal Influenza Vaccine. January 15, 2000.
  3. Nichol K, et al. Effectiveness of live, attenuated intranasal influenza virus vaccine in healthy, working adults. A randomized controlled trial. JAMA July 14, 1999;282: 137-44.
  4. Smith NM, Bresee JS, Shay DK, et al. Advisory Committee of Immunization Practices. Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practice (ACIP). MMWR Recomm Rep. 2006;55 (RR-10):1-42.
  5. Loeb M. Community acquired pneumonia. In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; April 2007.
  6. U.S. Food and Drug Administration (FDA). FDA approves nasal influenza vaccine for use in younger children. FDA News. Rockville, MD: FDA; September 19, 2007.
  7. U.S. Food and Drug Administration (FDA). Additional influenza vaccine approved for upcoming season. Approval increases number of available doses to record level. FDA News. Rockville, MD: FDA; September 28, 2007.
  8. Lewis EN, Friffin MR, Szilagy PG, et al. Childhood influenza. Number need to vaccinate to prevent 1 hospitalization or outpatient visit. Pediatrics. 2007;120(3): 467-472.
  9. Treanor JD. Influenza-The goal of control. N Engl J Med. 2007; 357(14):1439-1441.
  10. Centers of Disease Control and Prevention (CDC). Division of Media Relations. CDC's advisory committee recommends influenza vaccination for children 6 months through 18 years of age. Press Release. Atlanta, GA; CDC; February 27, 2008.
  11. Fiore AE, Shay DK, Broder K, et al. Centers for Disease Control and Prevention (CDC): Advisory Committee on Immunization Practices (ACIP). Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP). 2008. MMWR Recomm Rep. 2008;57 (RR-7):1-60.
  12. U.S. Food and Drug Administration (FDA). FDA Approve 2008-2009 Flu Vaccines. FDA News. Rockville, MD: FDA ; August 5, 2008.
  13. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a.htm

Coding Section

Codes Number Description
CPT 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
  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)

  90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)
  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)   
  90473 Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid)
  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)
  90630 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use
  90653 Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use
  90654 Influenza virus vaccine, trivalent (IIV3), split virus, preservative-free, for intradermal use
  90655 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use 
  90655 (effective 1/1/2017) Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for intramuscular use
  90656 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use
  90656 (effective 8/1/2016)  Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for inramuscular use
  90657 Influenza virus vaccine, trivalent (IIV3), split virus, when administered to children 6-35 months of age, for intramuscular use
  90657 (effective 8/1/2016)  Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use 
  90658 Influenza virus vaccine, trivalent (IIV3), split virus, when administered to individuals 3 years of age and older, for intramuscular use
  90658 (effective 1/1/2017)  Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use
  90660 Influenza virus vaccine, trivalent, live (LAIV3), for intranasal use
  90661 Influenza virus vaccine (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use
  90661 (effective 8/1/2016)  Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservation and antibiotic free, 0.5 mL dosage, for intramuscular use 
  90662 Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use
  90664 Influenza virus vaccine, live (LAIV), pandemic formulation, for intranasal us
  90666 Influenza virus vaccine (IIV), pandemic formulation, split virus, preservative free, for intramuscular use 
  90667 Influenza virus vaccine (IIV), pandemic formulation, split virus, adjuvanted, for intramuscular use
  90668 Influenza virus vaccine (IIV), pandemic formulation, split virus, for intramuscular use  
  90672 Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use
  90673 Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use   
  90674 (effective 8/1/2016)  Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subnit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use  
  90682 (effective 1/01/2018)  INFLUENZA VIRUS VACCINE, QUADRIVALENT (RIV4), DERIVED FROM RECOMBINANT DNA, HEMAGGLUTININ (HA) PROTEIN ONLY, PRESERVATIVE AND ANTIBIOTIC FREE, FOR INTRAMUSCULAR USE 
  90685 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use 
  90685 (effective 8/1/2016)  Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for intramuscular use
  90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use 
  90686 (effective 8/1/2016)  Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use
  90687 Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to children 6-35 months of age, for intramuscular use
  90687 (effective 8/1/2016)  Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL dosage, for intramuscular use
  90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to individuals 3 years of age and older, for intramuscular use
  90688 (effective 8/1/2016)  Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage, for intramuscular use
  90694  INFLUENZA VIRUS VACCINE, QUADRIVALENT (AIIV4), INACTIVATED, ADJUVANTED, PRESERVATIVE FREE, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE 
  90756 (effective 1/1//2018)   Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use  
HCPCS G0008 Administration of influenza virus vaccine
  G0009 Administration of pneumococcal vaccine
  G0010 Administration of hepatitis B vaccine
  Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (AFLURIA) 
  Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLULAVAL)
  Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLUVIRIN)
  Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone) 
  Q2039 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified) 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

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 2014 Forward     

06/08/2020 

Correcting typo in history box dated 5/28/2020. Added code 90694 to coding section. No other changes made 

05/28/2020 

Adding code 90967 to coding section. No other changes made. 

09/01/2019 

Annual review, no change to policy intent. 

09/05/2018 

Annual review, no change to policy intent. 

02/07/2018 

Correction of date in coding section. No other changes made. 

08/24/2017 

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

03/01/2017 

Updated CPT Coding. 

09/19/2016 

Updated CPT coding effective date. Updated rationale tables. 

08/03/2016 

Updated CPT coding in policy.   

08/31/2015

Annual review, no change to policy intent. Adding coding and updating table 1 to current ACIP recommendations. 

08/18/2015 

Changed review to September, as the 2015/2016 CDC recommendations have not been released yet. 

08/11/2014

Annual review, no changes made.


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