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DESCRIPTIONInfluenza (“flu”) is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness, and at times can lead to death. Complications of flu can include bacterial pneumonia, ear infections, sinus infections, dehydration, and worsening of chronic medical conditions.
The single best way to prevent the flu is to get vaccinated each season. There are two types of influenza vaccine: the injection and the nasal spray. Influenza viruses are always changing. Each year scientists try to match the viruses in the vaccine to those most likely to cause the flu that year. Yearly flu vaccination should begin in September, or as soon as vaccine is available, and continue throughout the flu season. The timing and duration of flu seasons vary. Although the flu season can begin as early as October, most of the time seasonal flu activity peaks in January or later.
The influenza injection is an inactivated (killed) vaccine given into the muscle. It is indicated for use in people six months of age and older, including healthy people, people with chronic medical conditions, and pregnant women.
The nasal spray influenza vaccine is a vaccine made with live, attenuated (weakened) influenza viruses that do not cause the flu. The nasal spray flu vaccine is an option for healthy people who do not have an underlying medical condition that predisposes them to influenza complications and are not pregnant. Even people who live with or care for those in a high risk group can get the nasal spray flu vaccine as long as they are healthy themselves. The one exception is health care workers who care for people with severely weakened immune systems who require a protected hospital environment.
About two weeks after vaccination, antibodies develop that protect against influenza virus infection for approximately one year.
Inactivated influenza vaccine injection is indicated and considered medically necessary for active immunization of individuals *6 months of age and older against influenza disease caused by influenza virus subtypes A and type B contained in the vaccine.
Inactivated influenza vaccine injection is not recommended for patients who have a history of hypersensitivity to egg proteins or other components of the vaccine, or life-threatening reaction to previous influenza vaccination.
Live attenuated influenza vaccine (FluMist®) or FluMist® Quadrivalent is indicated and considered medically necessary for active immunization of individuals 2-49 years of age against influenza disease caused by influenza virus subtypes A and type B contained in the vaccine.
Neither FluMist® nor FluMist® Quadrivalent is recommended for patients who are pregnant, immunocompromised, actively wheezing, less than 5 years of age and currently wheezing, have a history of Guillain-Barre syndrome within six weeks prior to any influenza vaccination, or have asthma or other underlying medical condition that predisposes them to influenza complications.
Children 2-8 years not previously vaccinated with influenza vaccine should receive 2 doses of FluMist® or FluMist® Quadrivalent (0.2mL each at least 1 month apart). Children 2-8 years previously vaccinated with influenza vaccine should receive 1 dose (0.2mL) of FluMist® or FluMist® Quadrivalent. Children, adolescents, and adults 9-49 years should also receive 1 dose (0.2mL) of FluMist® or FluMist® Quadrivalent.
Effective 10/23/15: For children ages 0 – 11 years, all flu vaccines must be provided and administered in the provider’s office to be covered. Flu vaccines for children ages 0 – 11 years are not covered when purchased or administered at a pharmacy.
FluMist® or FluMist® Quadrivalent must be provided and administered in the provider’s office to be covered. FluMist® and FluMist® Quadrivalent are not covered when purchased or administered at a pharmacy.
*Refer to the Prescribing Information of the specific vaccine to be administered (i.e. Fluzone, Afuria, Fluvirin) for the approved ages, dosage, and administration.
POLICY EXCEPTIONSFederal Employee Program (FEP)
State Health Plan (State and School Employees)
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY12/01/2010: Policy added.
12/30/2010: The scope of the policy was expanded to include inactivated influenza vaccine. Policy title changed from “Live Attenuated Influenza Vaccine (FluMist®)” to “Influenza Vaccine.” Policy statement updated to add information regarding the coverage of inactivated influenza vaccine. Policy statement updated to add the covered settings for vaccine administration. Added CPT codes 90655 – 90658 to the Code Reference section.
01/07/2013: Added coverage guidelines for FluMist® Quadrivalent. Added the following new 2013 CPT code to the Code Reference section: 90672.
02/20/2014: Removed CPT codes from Code Reference section and provided the link to the Healthy You! Wellness Procedures Coding Guidelines.
07/30/2015: Code Reference section updated for ICD-10.
12/01/2015: Policy section updated to state that effective 10/23/15, for children ages 0-11 years, all flu vaccines must be provided and administered in the provider's office to be covered. Flu vaccines for children ages 0-11 years are not covered when purchased or administered at a pharmacy. The previous age range was "0-18 years." Policy guidelines updated to add medically necessary and investigational definitions.
SOURCE(S)FluMist® Prescribing InformationCenters for Disease Control and Prevention www.cdc.gov
Inactivated influenza virus vaccine Prescribing Information
FluMist® Quadrivalent Prescribing Information
Coverage will only be made for covered codes when used for services outlined within the Healthy You! Wellness Procedures coding guidelines.