Medical Policy

Effective Date:01/01/2002 Title:Hepatitis A Vaccine
Revision Date:09/01/2018 Document:BI120:00
CPT Code(s):90632-9634, 90636
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Hepatitis A vaccine is recommended for routine immunization of all infants and small children. QualChoice covers this vaccine under the preventive benefit without preauthorization for all infants and children under the age of 18.

a)  Infants and small children are the most likely to get hepatitis A.

b)  Infants and small children are rarely ill from hepatitis A, but they do spread it to older people in their surroundings.

2)    Hepatitis A vaccine is not recommended for immunization of adults without risk factors (unless there is a documented community outbreak) and is therefore covered for adults (age 18 and older) with increased risk under the medical benefit without preauthorization.

3)    Hepatitis A vaccine may be recommended based on certain occupations or for travel to countries where Hepatitis A is prevalent, however, QualChoice plans do not provide coverage for these uses.

Medical Statement

1)    QualChoice covers (under the preventive benefit) routine vaccination in either the 2-dose or 3-dose schedule of infants and children under 18 years of age. Physicians are encouraged to vaccinate children at 12 to 23 months of age, since it is of maximum public health benefit when infants are immunized.

2)    Hepatitis A vaccine is considered medically necessary (under the medical benefit) for adults (ages 18 and older) only in the following scenarios:

a)    Homosexual men

b)    Persons with chronic liver disease. including hepatitis C

c)    Unvaccinated persons who are adopting infants from foreign counties

d)    Community outbreak of hepatitis A

e)    If member requests the Hepatitis A vaccine due to high risk

Codes Used In This BI:

90632

Hepatitis A vaccine, adult dosage, for IM use

90633

Hepatitis A vaccine, pediatric/adoles dosage – 2 dose sched, for IM use

90634

Hepatitis A vaccine, pediatric/adoles dosage – 3 dose sched, for IM use

90636

Hepatitis A & Hepatitis B vaccine (HepA-HepB), adult dosage, for IM use

Limits

Hepatitis A vaccine is excluded from coverage for the following categories:

    1. Travelers to areas where hepatitis A is endemic
    2. Military personnel
    3. Individuals with occupational risk of exposure, such as child-care and institutional workers, as well as primate-animal handlers
    4. Laboratory workers who handle live hepatitis A virus.
Reference

1.    Hepatitis A in Hispanic Children Who Live Along the United States–Mexico Border: The Role of International Travel and Food-Borne Exposures; Pediatrics at: http://pediatrics.aappublications.org/cgi/content/abstract/114/1/e68

2.    Prevention of hepatitis A infections: guidelines for use of hepatitis A vaccine and immune globulin. American Academy of Pediatrics Committee on Infectious Diseases; Pediatrics at: http://pediatrics.aappublications.org/cgi/content/abstract/98/6/1207

3.    Prevention of hepatitis A through active or passive immunization.  Recommendations of the Advisory Committee on Immunization Practices (ACIP) 2006.  Accessed 1 July 2014 at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5507a1.htm

Addendum:

1)    Effective 01/01/2019: Remove PA requirements for vaccine. Will be covered as routine preventive benefit for ages <18 years old and under the medical benefit as medically necessary under certain scenarios for ages >18 years or older.

2)    Effective 09/01/2021: Added verbiage to remove restrictions on testing.

Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD,  EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.