Vaccinations: Clinical Policy (Effective 10/01/2013)

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CLINICAL POLICY

VACCINES

The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern. CONDITIONS OF COVERAGE Applicable Lines of Business/Products

This policy applies to Oxford Commercial plan membership

Benefit Type General benefits package

Referral Required (Does not apply to non-gatekeeper products)

No

Authorization Required (Precertification always required for inpatient admission)

No

Precertification with Medical Director Review Required

No

Applicable Site(s) of Service (If site of service is not listed, Medical Director review is required)

All

Note: Pneumococcal and influenza vaccines will be reimbursed regardless of the provider or setting in which they are furnished.

Policy Number: VACCINES 005.38 T0 Effective Date: October 1, 2013

Table of Contents CONDITIONS OF COVERAGE................................... COVERAGE RATIONALE........................................... BENEFIT CONSIDERATIONS.................................... BACKGROUND........................................................... APPLICABLE CODES................................................. REFERENCES............................................................ POLICY HISTORY/REVISION INFORMATION...........

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Related Policies: Preventive Care

Vaccinations: Clinical Policy (Effective 10/01/2013)

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COVERAGE RATIONALE Oxford provides coverage for immunizations/vaccinations except where specifically excluded. Examples of the most common coverage exclusions include immunizations that are required for travel, employment, education, insurance, marriage, adoption, military service, or other administrative reasons. Refer to the Member's specific certificate of coverage, evidence of coverage, summary of benefits and/or health benefits plan documentation for additional information. Immunizations that are not classified as a "coverage exclusion" by the Member's plan are considered covered after all of the following conditions are satisfied:

1. US Food and Drug Administration (FDA) approval; and 2. Advisory Committee on Immunization Practices (ACIP) definitive ("shall") recommendation

rather a permissive ("may") recommendation published in the Morbidity & Mortality Weekly Report (MMWR) of the Centers for Disease Control and Prevention (CDC).

BENEFIT CONSIDERATIONS The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) web site contains the most current information regarding the use of vaccines and immunizations in the United States, including both recommendations/schedules and precautions.

• ACIP Recommendations: http://www.cdc.gov/vaccines/pubs/ACIP-list.htm

Oxford further provides coverage for re-vaccination and off schedule vaccinations as determined appropriate by the Member's physician or other healthcare practitioner. Oxford covers certain services under the Preventive Care Services benefit. Effective for plan years on or after September 23, 2010, the federal Patient Protection and Affordable Care Act (PPACA) requires non-grandfathered plans to cover certain preventive services identified by PPACA. For non-grandfathered plans, and for grandfathered plans wishing to offer such coverage, Oxford will cover preventive services as mandated by Federal Patient Protection and Affordable Care Act (PPACA), with no cost sharing when provided by a network provider for those vaccines with a definitive approval from ACIP of the CDC. Refer to policy: Preventive Care for more information related to immunizations/vaccinations. BACKGROUND Disease prevention is extremely important in the realm of public health. Vaccines prevent disease in the people who receive them and protect those who come into contact with unvaccinated individuals. Vaccines are responsible for the control of many infectious diseases that were once common in the United States, including polio, measles, diphtheria, pertussis (whooping cough), rubella (German measles), mumps, tetanus, and Haemophilus influenzae type b (Hib). Immunization, also known as vaccination, is a means of triggering acquired immunity. This is a specialized form of immunity that provides long-lasting protection against specific antigens, such as certain diseases. Small doses of an antigen (such as dead or weakened live viruses) are given to activate the body's immune system APPLICABLE CODES The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the Member’s plan of benefits or Certificate of Coverage. This list of codes may not be all inclusive.

Vaccinations: Clinical Policy (Effective 10/01/2013)

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Immunization Administration Applicable CPT/HCPCS Codes CPT® Code Description

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)

HCPCS Code

Description

G0008 Administration of influenza virus vaccine G0009 Administration of pneumococcal vaccine G0010 Administration of hepatitis B vaccine

CPT® is a registered trademark of the American Medical Association Vaccination Products Applicable CPT/HCPCS Codes CPT® Code Description

90375 Rabies immune globulin (RIg), human, for intramuscular and/or subcutaneous use

90376 Rabies immune globulin, heat-treated (RIg-HT), human, for intramuscular and/or subcutaneous use

90476 Adenovirus vaccine, type 4, live, for oral use 90477 Adenovirus vaccine, type 7, live, for oral use

90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use

90586 Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use

90632 Hepatitis A vaccine, adult dosage, for intramuscular use

90633 Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for intramuscular use

90634 Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for intramuscular use

90636 Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use

90645 Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for intramuscular use

90646 Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use

90647 Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use

Vaccinations: Clinical Policy (Effective 10/01/2013)

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CPT® Code Description

90648 Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use

90649 Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use Note: Coverage is limited to patients age 9-26. Coverage ends on 27th birthday.

90650* Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use Note: Coverage is limited to females age 9 - 26. Coverage ends on 27th birthday.

90654 Influenza virus vaccine, split virus, preservative free, for intradermal use

90655 Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use

90656 Influenza virus vaccine, trivalent, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use

90657 Influenza virus vaccine, trivalent, split virus, when administered to children 6-35 months of age, for intramuscular use

90658 Influenza virus vaccine, trivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use

90660 Influenza virus vaccine, trivalent, live, for intranasal use Note: Coverage is limited to ages 2 - 49. Coverage ends on 50th birthday.

90661 Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use

90662 Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use Note: Coverage is limited to ages 65+.

90664 Influenza virus vaccine, pandemic formulation, live, for intranasal use

90666 Influenza virus vaccine, pandemic formulation, split virus, preservative free, for intramuscular use

90667 Influenza virus vaccine, pandemic formulation, split virus, adjuvanted, for intramuscular use

90668 Influenza virus vaccine, pandemic formulation, split virus, for intramuscular use 90669 Pneumococcal conjugate vaccine, 7 valent, for intramuscular use 90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use 90672 Influenza virus vaccine, quadrivalent, live, for intranasal use 90675 Rabies vaccine, for intramuscular use 90676 Rabies vaccine, for intradermal use 90680 Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use 90681 Rotavirus vaccine, human, attenuated, 2 dose schedule, live, for oral use

90685 Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use

90686 Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use

90696 Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated (DTaP-IPV), when administered to children 4 years through 6 years of age, for intramuscular use

90698 Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated (DTaP - Hib - IPV), for intramuscular use

90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use

90702 Diphtheria and tetanus toxoids (DT) adsorbed when administered to individuals younger than 7 years, for intramuscular use

90703 Tetanus toxoid adsorbed, for intramuscular use 90704 Mumps virus vaccine, live, for subcutaneous use 90705 Measles virus vaccine, live, for subcutaneous use 90706 Rubella virus vaccine, live, for subcutaneous use 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use

Vaccinations: Clinical Policy (Effective 10/01/2013)

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CPT® Code Description 90708 Measles and rubella virus vaccine, live, for subcutaneous use

90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use

90712 Poliovirus vaccine, (any type[s]) (OPV), live, for oral use 90713 Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use

90714 Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when administered to individuals 7 years or older, for intramuscular use

90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use

90716 Varicella virus vaccine, live, for subcutaneous use 90719 Diphtheria toxoid, for intramuscular use

90720 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus influenza B vaccine (DTP-Hib), for intramuscular use

90721 Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for intramuscular use

90723 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DtaP-HepB-IPV), for intramuscular use

90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use

90733 Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use

90734 Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use

90736 Zoster (shingles) vaccine, live, for subcutaneous injection Note: Coverage for the Zoster vaccine is limited to age 60+

90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use

90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use

90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use

90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use

90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use

90748 Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use

90749 Unlisted vaccine/toxoid

HCPCS Code Description

Q2033 (effective 7/1/2013)

Influenza vaccine, recombinant Hemagglutinin antigens for intramuscular use (Flublok)

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

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)

CPT® is a registered trademark of the American Medical Association.

*CPT 90650 is reimbursable for females only **HCPCS Code Q2034 is effective for dates of service 07/01/2012 and after.

Vaccinations: Clinical Policy (Effective 10/01/2013)

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Travel Vaccination Products Non-Reimbursable CPT Codes

CPT Code Description 90690 Typhoid vaccine, live, oral 90691 Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use

90692 Typhoid vaccine, heat- and phenol-inactivated (H-P), for subcutaneous or intradermal use

90693 Typhoid vaccine, acetone-killed, dried (AKD), for subcutaneous use (U.S. military)

90717 Yellow fever vaccine, live, for subcutaneous use 90725 Cholera vaccine for injectable use 90727 Plague vaccine, for intramuscular use 90735 Japanese encephalitis virus vaccine, for subcutaneous use 90738 Japanese encephalitis virus vaccine, inactivated, for intramuscular use

CPT® is a registered trademark of the American Medical Association. Vaccination Products Pending FDA Approval Non-Reimbursable CPT Codes

CPT Code Description

90644 Meningococcal conjugate vaccine, serogroups C & Y and Hemophilus influenza B vaccine (Hib-MenCY), 4 dose schedule, when administered to children 2-15 months of age, for intramuscular use

90653 Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use

90687 Influenza virus vaccine, quadrivalent, split virus, when administered to children 6-35 months of age, for intramuscular use

90688 Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use

90739 Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use CPT® is a registered trademark of the American Medical Association.

REFERENCES The foregoing Oxford policy has been adapted from an existing UnitedHealth Pharmaceutical Solutions Clinical Pharmacy Program that was researched, developed and approved by the UnitedHealthcare National Pharmacy & Therapeutics Committee. [2013D0031G] 1. Department of Health and Human Services. Centers for Disease Control and Prevention

(CDC). ACIP Recommendations. Available at http://www.cdc.gov/vaccines/pubs/ACIP-list.htm.

2. Department of Health and Human Services. Centers for Disease Control and Prevention (CDC). How Vaccines Prevent Disease. Available at http://www.cdc.gov/vaccines/vac-gen/howvpd.htm.

3. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/default.htm. Accessed March February 24, 2011.

4. American Medical Association. Current Procedural Terminology: CPT, Professional Edition. 5. Ingenix. Healthcare Common Procedure Coding System: HCPCS Level II Expert.

POLICY HISTORY/REVISION INFORMATION

Date Action/Description

10/01/2013

• Updated list of applicable (reimbursable) CPT codes for vaccination products; added 90685 (previously listed as non-reimbursable/pending FDA approval)

• Archived previous policy version VACCINES 005.37 T0