Coverage Policies

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.    Immunizations recommended for routine administration to children and adults by the Center for Disease Control of the US Department of Health, or similarly authoritative body, will be covered under the preventive benefit. Coverage includes payment both for the cost of the immunization materials and for the administration fee. Immunizations that are not recommended for routine administration, but may be given on an as needed basis for medical reasons, will be covered under the medical benefit. Immunizations not covered as routine and which are intended primarily for travel, or required for work, school, or camp, are not covered.

2.    Reference to the member’s coverage documents and benefit summary is necessary to determine specific preventive health benefit coverage. The Enrollee should be aware of special benefits, limits, and/or restrictions on preventive treatments, in particular whether the service is covered when obtained out of network. 

3.    For coverage on flu immunizations, please refer to BI010.

An immunization is a routinely administered medication to prevent a specific disease in someone with a normally functioning immune system. The QualChoice Preventive Health Care Guidelines recommends the following immunizations as suggested by the Center for Disease Control and the National Immunization Program. 

INFANT AND CHILDHOOD IMMUNIZATIONS

Ages Birth – 6 years

The following immunization(s) are covered:

·      90633 – Hepatitis A vaccine, pediatric/adolescent dosage – 2 dose schedule, IM     use under age 18

·      90634 – Hepatitis A vaccine, pediatric/adolescent dosage – 3 dose schedule, IM     use under age 18

·      90644 – Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus influenza type B vaccine (Hib-MenCY) 4 dose sched, ages 6 weeks – 18 mths, IM use

·      90647 – Haemophilus influenza type B vaccine, 3 dose schedule, IM use

·      90648 – Haemophilus influenza type B vaccine, 4 dose schedule, IM use

·      90680 – Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, oral use, for children ages 2 – 9 months

·      90681 – Rotavirus vaccine, human, attenuated (RV1), 2 dose schedule, live, oral use

·      90696 – DTaP-IPV, IM use

·      90697 – DTaP-IPV-Hib-HepB, IM use

·      90698 – DTaP-IPV/Hib, IM use

·      90700 – DTaP, IM use, for children younger than 7 years of age

·      90702 – DT (diphtheria/tetanus), IM use, for children younger than 7 years of age

·      90723 – DTaP-HepB-IPV, IM use

·      90748 – Hepatitis B and Haemophilus influenza type b vaccine (Hib-HepB), IM use

ADOLESCENT AND ADULT IMMUNIZATIONS

COVID-19 Vaccine Administration – Monovalent vaccines are no longer covered or available.

COVID-19 vaccine administration codes are covered as preventive as follows:

Age 6 months – 4 years

91308             Vaccine Treatment (Pfizer) Pediatric

0081A            Vaccine Treatment (Pfizer) Pediatric 1st dose

0082A            Vaccine Treatment (Pfizer) Pediatric 2nd dose

0083A            Vaccine Treatment (Pfizer) Pediatric 3rd dose

91317             Vaccine Treatment (Pfizer) Pediatric Bivalent

0171A            Vaccine Treatment (Pfizer) 1st Dose

0172A            Vaccine Treatment (Pfizer) 2nd Dose

0173A            Vaccine Treatment (Pfizer) 3rd Dose

0174A            Vaccine Treatment (Pfizer) Additional Dose

Age 6 months – 5 years

91311             Vaccine Treatment (Moderna) Pediatric

0111A            Vaccine Treatment (Moderna) Pediatric 1st Dose

0112A            Vaccine Treatment (Moderna) Pediatric 2nd Dose

0113A            Vaccine Treatment (Moderna) Pediatric 3rd Dose

91316             Vaccine Treatment (Moderna) Pediatric Bivalent

0164A            Vaccine Treatment (Moderna) Pediatric Additional Dose

Age 6 months – 11 years

91314             Vaccine Treatment (Moderna) Pediatric

0141A            Vaccine Treatment (Moderna) Bivalent 1st Dose

0142A            Vaccine Treatment (Moderna) Bivalent 2nd Dose

0144A            Vaccine Treatment (Moderna) Bivalent Additional Dose

Age 5-11

91307             Vaccine Treatment (Pfizer) Pediatric

0071A            Vaccine Treatment (Pfizer) Pediatric 1st Dose

0072A            Vaccine Treatment (Pfizer) Pediatric 2nd Dose

0073A            Vaccine Treatment (Pfizer) Pediatric 3rd Dose

0074A            Vaccine Treatment (Pfizer) Pediatric Booster

91315             Vaccine Treatment (Pfizer) Pediatric Bivalent

0151A            Vaccine Treatment (Pfizer) Pediatric 1st Dose

0154A            Vaccine Treatment (Pfizer) Pediatric Additional Dose

Age 6 – 11

91309             Vaccine Treatment (Moderna) Pediatric

0091A            Vaccine Treatment (Moderna) Pediatric 1st Dose

0092A            Vaccine Treatment (Moderna) Pediatric 2nd Dose

0093A            Vaccine Treatment (Moderna) Pediatric 3rd Dose

12 and older

91300             Vaccine Treatment (Pfizer)

0001A            Vaccine Treatment (Pfizer) 1st Dose

0002A            Vaccine Treatment (Pfizer) 2nd Dose

0003A            Vaccine Treatment (Pfizer) 3rd Dose

0004A            Vaccine Treatment (Pfizer) Booster

91304             Vaccine Treatment (Novavax)

0041A            Vaccine Treatment 1st Dose

0042A            Vaccine Treatment 2nd Dose

91305             Vaccine Treatment (Pfizer) Ready to Use

0051A            Vaccine Treatment (Pfizer) Ready to Use 1st Dose

0052A            Vaccine Treatment (Pfizer) Ready to Use 2nd Dose

0053A            Vaccine Treatment (Pfizer) Ready to Use 3rd Dose

0054A            Vaccine Treatment (Pfizer) Ready to Use Booster

91312             Vaccine Treatment (Pfizer) Bivalent

0121A            Vaccine Treatment (Pfizer) 1st Dose

0124A            Vaccine Treatment (Pfizer) additional dose

91301             Vaccine Treatment (Moderna)

0011A            Vaccine Treatment (Moderna) 1st Dose

0012A            Vaccine Treatment (Moderna) 2nd Dose

0013A            Vaccine Treatment (Moderna) 3rd Dose

91304             Vaccine Treatment (Novovax)

0044A            Vaccine Treatment (Novavax) Booster)

91313             Vaccine Treatment (Moderna) Bivalent

0134A            Vaccine Treatment (Moderna) Additional Dose

18 and older

91302             Vaccine Treatment (AstraZeneca)

0021A            Vaccine Treatment (AstraZeneca) 1st Dose

0022A            Vaccine Treatment (AstraZeneca) 2nd Dose

91306             Vaccine Treatment (Moderna) Low Dose

0064A            Vaccine Treatment (Moderna) Low Dose Booster

91309             Vaccine Treatment (Moderna)

0094A            Vaccine Treatment (Moderna) Booster

91303             Vaccine Treatment (Janssen)

0031A            Vaccine Treatment (Janssen) Single Dose

0034A            Vaccine Treatment (Janssen) Booster

91310             Vaccine Treatment (SanofiPasteur)

0104A            Vaccine Treatment (Sanofi Pasteur) Booster

FEMALES, Age 9 – 26; 27-45

The following immunization(s) are covered:

·      90649 – Human Papillomavirus vaccine, types 6, 11, 16, 18, quadrivalent (4vHPV), 3 dose schedule, IM use

·      90651 – Human Papillomavirus vaccine, types 6, 11, 16, 18, 31, 33, 45, 52, 58,

Nonavalent (9vHPV), 2 or 3 dose schedule, IM use

If therapy initiated before the 15th birthday, a 2-dose schedule has been shown to be equally efficacious to the 3-dose schedule and is recommended by ACIP.

For ages 27-45, 90651 is covered for those individuals not adequately vaccinated.

MALES, Ages 9 – 26; 27-45

The following immunization(s) are covered:

·      90649 – Human Papillomavirus vaccine, types 6, 11, 16, 18, quadrivalent (4vHPV), 3 dose schedule, IM use

·      90651 – Human Papillomavirus vaccine, types 6, 11, 16, 18, 31, 33, 45, 52, 58,

Nonavalent (9vHPV), 2 or 3 dose schedule, IM use

If therapy initiated before the 15th birthday, a 2-dose schedule has been shown to be equally efficacious to the 3-dose schedule and is recommended by ACIP.

For ages 27-45, 90651 is covered for those individuals not adequately vaccinated.

Age 19 and younger

• 90743 – Hepatitis B vaccine (HepB), adolescent, 2 dose schedule, IM use
• 90744 – Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3 dose schedule, IM use

Age 26 and younger

The following immunization(s) are covered:

• 90707 – MMR, live, SC use covered for individuals born in 1957 or later.
• 90710 – MMRV, live, SC use
• 90713 – Poliovirus vaccine, inactivated (IPV), SC or IM use
• 90716 – Varicella virus vaccine (VAR), live, SC use
• 90619 – Meningococcal conj vaccine, serogroups A, C, W, Y quadrivalent, tetanus toxoid carrier (MenACWY-TT) for IM use
• 90620 – Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B (MenB-4C), 2 dose sched, IM use
• 90621 – Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB-FHbp), 2 or 3 dose sched, IM use
• 90733 – Meningococcal polysaccharide vaccine, serogroups A, C, Y, W-135, quadrivalent (MPSV4), SC use
• 90734 – Meningococcal conjugate vaccine, serogroups A, C, Y and W-135, quadrivalent (MenACWY), IM use

Age 50 and older

The following immunization(s) are covered:

• 90750 – Zoster (“Shingrix”) shingles vaccine, recombinant, sub-unit, adjuvanted, IM use, for ages 50 and over (with 2nd dose 2-6 months after 1st dose) The following immunizations are covered for appropriate ages as listed:  90714 – Td, adsorbed, preservative free, for individuals ages 7 and older, IM use.

The following vaccines should pay for appropriate ages as listed:

• 90715 – Tdap vaccine (tetanus, diphtheria toxoids and acellular pertussis), for individuals ages 7 and older, IM use
• 90670 – Pneumococcal Conjugate Vaccine, 13 valent (PCV13), IM use for all ages.
• 90677 – Pneumococcal Conjugate Vaccine, 20 valent (PCV20), IM use for all ages
• 90732 – Pneumococcal polysaccharide vaccine, 23-valent, (PPSV23), adult or

Immunosuppressed patient dosage, for individuals ages 2 and older, SC or IM use

Immunizations Not Routinely Covered

The following sections detail immunizations which are not routinely covered. They may be requested by a member for reasons particular to that member, and be administered by an attending physician who agrees with the need despite the expectation that QualChoice will not pay for the immunization. In such cases, a specific statement of acknowledgement of financial responsibility (similar to the Medicare ABN) should be signed by the member before the immunization is administered, to advise the member of his/her financial responsibility, and the amount of that responsibility. The member should be advised that the claim may be denied by QualChoice with no recognition of member liability, but that this does not release the member from financial responsibility to pay for the requested immunization.

Immunizations Subject to Medical Review

The following immunizations are covered when ordered by a physician and will be subject to medical necessity review:

a)    90476 – 90477 – Adenovirus vaccine, live, oral use

b)    90675 – 90676 – Rabies vaccine, IM/ID use, for those with confirmed or presumed rabies exposure

Immunizations required due to outbreak of disease in Arkansas will be covered as medically necessary and reported to the Arkansas Department of Health. These immunizations require preauthorization:

a)    90581 – Anthrax vaccine, SC or IM use

b)    90625 – Cholera vaccine, live, adult dosage, 1 dose schedule, oral use

c)    90690 – 90691 – Typhoid vaccine, IM use

d)    90740 – Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3 dose schedule, IM use, for ages 18 and up

e)    90747 – Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 4 dose schedule, IM use, for ages 18 and up

f)     90739 – Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule, IM use

g)    90746 – Hepatitis B vaccine (HepB), adult dosage, 3 dose schedule, IM use

h)    90749 – Unlisted vaccine/toxoid

Immunizations Not Covered

Immunizations not mentioned above as being routinely covered are not a covered benefit even when required for:

a)    Travel

b)    Employment

c)    Camp

d)    Attendance at school

New vaccines, new combination vaccines, and vaccines given through alternative routes will be reviewed as needed for medical necessity and for appropriateness of coverage according to the member’s benefit contract. 

New vaccines that are duplicates of already available vaccines, or which are different only because of reduced amounts of preservative in them, are covered at the same allowance as the standard vaccine.

The following immunizations are not covered because (a) there are better methods to prevent infection than immunization or (b) they are used exclusively for travel:

a)    90738 – Japanese encephalitis virus vaccine, inactivated, IM use

b)    90717 – Yellow Fever vaccine, live, SC use (used only for travel)

c)    90585 – BCG for tuberculosis, live, PC use (used only for travel)

d)    90586 – BCG for bladder cancer, live, intravesical use (used only for travel)

e)    90587 – Dengue vaccine, (used only for travel)

Codes Used In This BI:

1.    CDC Recommendations for Lyme disease vaccine. www.cdc.gov/vaccines

2.    American Academy of Pediatrics recommendations, http://www.aap.org/

3.    American Academy of Family Practice Physicians recommendations, http://www.aafp.org/

4.    National Immunization Information Hotline: 800-232-2552

5.    ACIP recommendations: http://www.cdc.gov/vaccines/pubs/ACIP-list.htm#meningHealth and Economic Implications of HPV Vaccination in the United States: NEJM August 2008 at: http://content.nejm.org/cgi/content/full/359/8/821

6.    CDC Immunization schedules at; http://www.cdc.gov/vaccines/recs/schedules/

7.    Recommendations of the ACIP on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR. January 26, 2018 / 67(3);103–108

Addendum:

1.    Effective 01/01/2017: Corrected statements regarding coverage of 90632 and 90636. 2017 Code Updates – Added new CPT code 90750, Shingles vaccine (HZV) to Age 60 and over group.

2.    Effective 05/01/2017: Updated coverage criteria for HPV to age 9 – 26 for both male and female. Added note regarding ACIP recommendation of 2–dose schedule if therapy initiated before 15th birthday.

3.    Effective 07/01/2017: Clarified verbiage for 90740 and 90747– Hepatitis B vaccine (HepB), dialysis or immunosuppressed patients require prior authorization.

4.    Effective 01/01/2018: 2018 Code Updates. Updated Claim Statement section & Codes Used in This BI section to reflect revised CPT/HCPCS code descriptions. The following codes were revised 1/1/18: 90620 – 90621 & 90651.

5.    Effective 04/01/2018: 90732 Pneumococcal polysaccharide vaccine, 23–valent, (PPSV23), adult or Immunosuppressed patient dosage, is covered for ages 2 – 64 years of age.

6.    Effective 05/01/2018: Adopted Shingrix recombinant vaccine at 50 yrs of age per ACIP.

7.    Effective 01/04/2019: Extended routine preventive coverage of Hep A vaccine through 17 yrs old and added medical coverage 18 yrs and up.

8.    Effective 05/07/2019: Aligned MMR coverage for adults with CDC DOB recommendations.

9.    Effective 07/01/2019: New code (90619) added for meningococcal vaccine.

10. Effective 01/01/2020: Eliminated coverage of Zostavax.

11. Effective 01/01/2020: Extended coverage age for 90732 (PPSV23) to include 65 or older and updated coverage for 90651 for ages 27-45.

12. Effective 02/01/2020: Clarified distinction between routine pediatric/adolescent Hep B vaccine coverage and adult Hep B vaccine coverage.

13. Effective 12/01/2021: Added codes for COVID-19 vaccine administration to coverage policy.

14. Effective 10/02/2021: Added 90677, code of Prevnar 20

15. Effective 06/01/2022: Updated COVID vaccine codes

16. Effective 06/01/2023: Added code 90671.

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.