Description
The U.S. Patient Protection and Affordable Care Act (PPACA) was passed by Congress and signed into law by the president in March 2010. The preventive services component of the law became effective Sept. 23, 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force (USPSTF).

Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.

Task force recommendations are graded on a five-point scale (A – E), reflecting the strength of evidence in support of the intervention. Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds. Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination. Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.

Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, coinsurance or copay) by Health Plans for appropriate preventive care services provided by an in-network provider. If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, coinsurance or copay may be applied.

Services are typically included as part of a normal wellness visit; the appropriate office visit code should be used. Evaluation and Management codes for preventive services 99381 – 99397 will always be considered preventive. CPT Codes 99401 – 99404, when used to designate a preventive service, must have the applicable wellness/preventive diagnosis code as the primary reason for the visit.

When the primary purpose of the service is the delivery of an evidence-based service in accordance with a U.S. Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33.'

TRAVEL IMMUNIZATIONS ADDITIONAL INFORMATION:

Immunizations that are specific to travel (e.g., typhoid, yellow fever, cholera, plague and Japanese encephalitis virus) are not required by PPACA and are excluded from coverage.  

NOTE: THIS POLICY APPLIES ONLY TO NONGRANDFATHERED PLANS.  

Background
The ACIP develops recommendations on how to use vaccines to control disease in the United States. The recommendations include the age(s) when the vaccines should be given, the number of doses needed, the amount of time between doses and precautions and contraindications.

Professional organizations that work with the ACIP to develop the annual childhood and adult schedules include the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG) and the American College of Physicians (ACP).

The Committee's recommendations are forwarded to CDC’s director for approval. Once the ACIP recommendations have been reviewed and approved by the CDC director and the U.S. Department of Health and Human Services, they are published in CDC’s Morbidity and Mortality Weekly Report (MMWR). The MMWR publication represents the final and official CDC recommendations for immunization of the U.S. population.

Each year, the Advisory Committee on Immunization Practices (ACIP) publishes immunization schedules for persons age birth through 18 years. These schedules summarize recommendations for routine vaccines for children age 18 years and younger.

The recommended immunization schedules for persons age birth through 18 years and the catch-up immunization schedule have been approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics, the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists. 

Policy
The following immunizations are considered MEDICALLY NECESSARY when given in accordance with ACIP guidelines:

An immunization is considered NOT MEDICALLY NECESSARY if it does not meet Vaccine Policy requirements for FDA labeling (including age and/or gender limitations) and if it does not have definitive ACIP recommendations published in the CDC’s Morbidity and Mortality Weekly Report (MMWR).

• Age Group column: This column is provided for informational use only. For purposes of this document: Adult means age 18 years and up; pediatric means age 0 – 18 years.

• Benefit Limits column: Benefit Limits in bold text are from FDA labeling and ACIP recommendations. Codes that indicate “For applicable age, see code description” are limited to the age(s) listed in the code description.

PREVENTIVE IMMUNIZATIONS

These codes do not have a diagnosis code requirement for preventive benefits to apply. 

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.

References

1. http://www.cdc.gov/vaccines/acip/recs/index.html 
2. http://www.cdc.gov/vaccines/hcp/acip-recs/index.html 
3. http://www.cdc.gov/vaccines/schedules/hcp/index.html 
4. http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf 
5. http://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html 
6. http://www2a.cdc.gov/vaccines/iis/iisstandards/vaccines.asp?rpt=cpt
7. http://www.cdc.gov/flu/protect/vaccine/vaccines.htm

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 Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved"  

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