Medical Policy

 

Subject: Immunizations
Document #: ADMIN.00007 Publish Date:    08/29/2018
Status: Revised Last Review Date:    07/26/2018

Description/Scope

This document addresses the use of childhood and adult immunizations as recommended by the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and the Advisory Committee on Immunization Practices (ACIP) for the Centers for Disease Control and Prevention (CDC). Immunization is a technique used to induce immune resistance to a specific disease in humans by exposing the individual to an antigen in order to raise antibodies to that antigen. This process increases an individual’s reaction to an antigen and therefore improves the ability to resist or overcome infection.

Position Statement

Medically Necessary:

For Childhood Immunizations:
The most recent recommendations of the American Academy of Family Physicians (AAFP), or the American Academy of Pediatrics (AAP), or the affirmative recommendations of the Advisory Committee on Immunization Practices (ACIP) for the Centers for Disease Control and Prevention (CDC) for childhood immunizations are considered medically necessary.

For Adult Immunizations:
The most recent recommendations of the American Academy of Family Physicians (AAFP) or affirmative recommendations of the Advisory Committee on Immunization Practices (ACIP) for the Centers for Disease Control and Prevention (CDC) for adult immunizations are considered medically necessary.

Not Medically Necessary:

Childhood and adult immunizations are considered not medically necessary for all other indications not listed above.

Note:
Permissive recommendations of the Advisory Committee on Immunization Practices (ACIP) for the Centers for Disease Control and Prevention (CDC) for childhood and adult immunizations are reviewed on an individual basis to determine medical necessity and will be listed in the position statement of this document when determined to be not medically necessary.

Rationale

Generally, immunizations are among the safest and most effective medicines. The overwhelming majority of medical experts in the United States and abroad believe that the benefits of complete immunization far outweigh the risks. The health experts in many countries are in full accord with the concept that everyone who is healthy should be immunized as recommended.

ACIP, a United States federal advisory committee, provides guidance to the Secretary and the Assistant Secretary for Health and Human Services, and the Director of the CDC, regarding vaccines and related agents for control of vaccine-preventable diseases within the United States. As a result of the Omnibus Budget Reconciliation Act of 1993, ACIP assumed the role of developing a list of vaccines for administration to children eligible to receive vaccines through the Vaccines for Children (VFC) Program, along with schedules regarding correct dosages, dosing intervals, and contraindications applicable to pediatric vaccines. VFC resolutions passed by ACIP form the basis for VFC program policies on vaccine availability and usage.

Recommendations developed by ACIP may be either affirmative or permissive recommendations. Affirmative recommendations are characterized as routine, catch-up, and risk-based. Routine vaccinations are most commonly implemented for a specific age group; catch-up vaccinations are usually for defined periods of time and cohorts; and risk-based recommendations are typically those for a high-risk population. A permissive recommendation is issued to reflect situations where vaccination may be effective, but ACIP is not recommending routine use.

On February 21, 2018, the ACIP voted to recommend any licensed, age-appropriate influenza vaccine for the 2018-2019 influenza season, including FluMist® Quadrivalent, a live attenuated influenza vaccine (LAIV) administered intranasally. This is a change from previous years, in which LAIV was not recommended for the 2016-2017 and 2017-2018 influenza seasons due to lower than expected effectiveness.

Background/Overview

Immunization is the process of inducing or providing immunity artificially by administering an immunobiologic. Immunization can be active or passive. Active immunization is the production of antibody or other immune responses through the administration of a vaccine or toxoid. Passive immunization means the provision of temporary immunity by the administration of preformed antibodies. Recommendations for vaccinating infants, children, and adults are based on characteristics of immunobiologics, scientific knowledge about the principles of active and passive immunization and the epidemiology of diseases, and judgments by public health officials and specialists in clinical and preventive medicine. Immunization programs help build defenses against disease and should be started early and carried out on a regular and routine basis.

Childhood immunizations consist of a series of intramuscular injections, subcutaneous injections, or oral dosing of inactivated bacteria, toxoids, live attenuated viruses, or inactive viral antigens against several diseases: diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, haemophilus influenzae type b, human papilloma virus (HPV), hepatitis A, hepatitis B, influenza, varicella, pneumococcus and rotavirus. Many of the immunizations are given as combined vaccines during routine well-child checks in the first 2 years of life. Immunizations against diseases for which risk factors are related to adolescent issues are recommended at ages prior to when exposure most frequently occurs. These include meningitis, hepatitis B, and human papillomavirus.

Most adult immunizations are administered in primary series (in previously unimmunized persons), booster doses, and periodic doses. Agents include toxoids (diphtheria and tetanus), live virus vaccines (measles, mumps, and rubella), influenza, inactive viral particles (hepatitis B), highly purified virus-like particles (HPV), and inactivated bacterial polysaccharide vaccine (pneumococcal).

Recommended immunization schedules are grouped by types of vaccine and the recipient’s age. Certain vaccinations are present on both childhood and adult schedules, while others may be limited to a specific schedule. For examples of age-specific ACIP recommendations, please see the following website: https://www.cdc.gov/vaccines/schedules.

Definitions

Antibody: A type of protein produced by the immune system in response to foreign substances that may be a threat to the body such as chemicals, virus particles, spores, or bacterial toxins. These foreign substances are called antigens. Each type of antibody is unique and defends the body against one specific type of antigen.

Antigen: Any substance that, when introduced into the body, evokes an immune response and stimulates the production of antibodies.

Coding

Coding edits for medical necessity review are not implemented for this administrative policy. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Family Physicians. Immunization schedules. Available at: http://www.aafp.org/online/en/home/clinical/immunizationres.html. Accessed on April 20, 2018.
  2. American Academy of Family Physicians. ACIP: LAIV OK to use during 2018-19 flu season. Available at: https://www.aafp.org/news/health-of-the-public/20180226acipmtg-laiv.html. Accessed on April 20, 2018.
  3. American Academy of Pediatrics. Immunization schedules. February 2018. Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/immunizations/Pages/Immunization-Schedule.aspx. Accessed on April 20, 2018.
  4. Centers for Disease Control and Prevention. ACIP votes down use of LAIV for 2016-2017 flu season. Available at: http://www.cdc.gov/media/releases/2016/s0622-laiv-flu.html. Accessed on April 20, 2018.
  5. Centers for Disease Control and Prevention. Heplisav-B® (HepB-CpG) Vaccine. Available at: https://www.cdc.gov/vaccines/schedules/vacc-updates/heplisav-b.html. Accessed on April 20, 2018.
  6. Centers for Disease Control and Prevention. Prevention and control of seasonal influenza with vaccines, 2017-18. Available at: https://www.cdc.gov/flu/professionals/acip/index.htm. Accessed on April 20, 2018.
  7. Centers for Disease Control and Prevention. Recommended immunization schedules for adults: United States, 2018. Available at: http://www.cdc.gov/vaccines/schedules/hcp/adult.html. Accessed on April 20, 2018.
  8. Centers for Disease Control and Prevention. Recommended immunization schedule for children and adolescents aged 18 years or younger, United States, 2018. Available at: http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html. Accessed on April 20, 2018.
Websites for Additional Information
  1. Centers for Disease Control and Prevention. Recommendations and guidelines: Advisory Committee on Immunization Practices (ACIP). Available at: http://www.cdc.gov/vaccines/acip/index.html. Accessed on April 21, 2018.
Index

Cervarix®
Diphtheria
FluMist® Quadrivalent
Gardasil®
Gardasil 9
Heplisav-B®
Herpes Zoster
HPV
Human Papillomavirus
Immunizations
Influenza
Inoculations
Live attenuated influenza vaccine
Measles
Meningococcal
MMR
Mumps
Pertussis
Pneumococcal
Poliovirus
Rotarix®
RotaTeq®
Rotavirus
Rubella
Shingrix
Td/Tdap
Tdap
Tetanus
Vaccines
Varicella

Document History

Status

Date

Action

Revised

07/26/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Removed NMN statement regarding the use of the live attenuated influenza vaccine. Updated Rationale, Background, References, and Websites sections. Updated Coding section to remove code 90672, no longer applicable.

 

05/10/2018

Added new vaccine to Index section. Background section updated.

 

02/28/2018

Added new vaccine to Index section. The document header wording updated from “Current Effective Date” to “Publish Date.”

Reviewed

08/03/2017

MPTAC review. Rationale and References sections updated.

Revised

08/04/2016

MPTAC review. Added new NMN statement regarding the use of the live attenuated influenza vaccine. Updated Coding, Rationale, Background/Overview and Reference sections.

Reviewed

02/04/2016

MPTAC review. Rationale, Background/Overview and Reference sections updated.

Reviewed

02/05/2015

MPTAC review. Description, Background, Reference and Index sections updated.

Reviewed

02/14/2014

MPTAC review. Rationale and Reference sections updated.

Reviewed

02/14/2013

MPTAC review. Reference section updated.

Revised

02/16/2012

MPTAC review. Added a not medically necessary statement. Description, Coding and Reference sections updated.

Reviewed

11/17/2011

MPTAC review. Rationale, Background, Description, Reference and Index sections updated. Immunization references moved from ADMIN.00002 to this document if not already present.

Reviewed

02/17/2011

MPTAC review. Rationale, Background and References updated.

Reviewed

02/25/2010

MPTAC review. Rationale and references updated.

Revised

11/19/2009

MPTAC review. Position statements updated to include affirmative ACIP recommendations and clarified by changing American Academy of Family Practice to American Academy of Family Physicians. Note regarding permissive recommendations added to position statement section. Description, rationale, background, and references updated.

 

02/19/2009

Updated references to reflect 2009 CDC releases.

Reviewed

11/20/2008

MPTAC review. Rationale section added. Background/Overview, references, and index updated.

Reviewed

11/29/2007

MPTAC review. References updated.

New

12/07/2006

MPTAC initial document development.

Pre-Merger Organizations Last Review Date Document Number Title

WellPoint Health Networks, Inc.

Archived 05/31/2002

      8.01.11

               Immunizations