Posted Aug. 3, 2021
Timely vaccinations can help protect your patients’ health. For patient safety, it’s important that you follow the U.S. Food and Drug Administration (FDA) guidelines and the Advisory Committee on Immunization Practices’ (ACIP) recommendations and child and adult immunization schedules.
How are claims affected?
Blue Cross and Blue Shield of Illinois (BCBSIL) reviews claims to ensure applicable guidelines are met. We’ve found that two categories of vaccines are often administered outside FDA and ACIP recommendations: those to prevent HPV and those to prevent shingles caused by the herpes zoster virus.
For these categories, if vaccines are administered outside of the FDA and ACIP recommendations,
- Consider the services to be experimental, investigational or unproven (EIU), which are not a covered benefit for BCBSIL members; and
- Recover reimbursements as per the claim payment recovery process outlined in our participating provider contracts.
BCBSIL will continue to reimburse medically necessary claims for vaccines administered according to FDA approval guidelines and ACIP recommended schedules.*
Know the Facts: HPV Vaccination
Gardasil 9 (9vHPV) is the vaccine for the prevention of HPV infections and associated diseases, including oropharyngeal and other head and neck cancers.
- As of October 2018, the FDA approved Gardasil 9 for women and men ages 9 to 45 years old.
- In June 2019, ACIP recommended catch-up vaccinations for women and men through age 26 years. ACIP also recommended vaccinating adults older than 26 years old. Involve your patients in the decision to vaccinate.
- For patients between 9 and 14 years old, ACIP recommends two or three doses. For patients between 15 and 45 years old, ACIP recommends three doses.
- As reported by the Centers for Disease Control and Prevention (CDC), as of the end of 2016, Gardasil 9 is the only HPV vaccine available in the U.S. Please check your systems and processes to avoid using 2vHPV or 4vHPV billing codes.
Know the Facts: Shingles Vaccinations
Shingrix and Zostavax help prevent shingles and its complications:
- Shingrix is approved by the FDA. ACIP recommends Shingrix for people age 50 years or older. It requires two doses. The second dose should be two to six months after the first.
- Zostavax is no longer available in the U.S. It was removed from the 2021 ACIP adult immunization schedule.
- In compliance with the FDA approval guidelines, BCBSIL considers Shingrix and Zostavax as medically necessary for anyone age 50 years or older. Note: Zostavax will be considered as medically necessity when rendered prior to the discontinuation of the drug.
The summary of the ACIP changes to the adult immunization schedule are in the Feb. 12, 2021, Morbidity and Mortality Weekly Report.
ACIP’s recommendations include immunization schedules for children and adolescents as well as adults, which can be found on the CDC website.
Also refer to BCBSIL’s Clinical Payment and Coding Policies (CPCPs) for our Preventive Services Policy (CPCP006).**
*Note regarding HMO members: Vaccines administered/referred by the HMO member’s Primary Care Physician (PCP) are covered by the member’s assigned HMO medical group. Medical necessity is determined by the member’s PCP.
**BCBSIL’s CPCPs don’t apply to members who have Medicare or Medicaid plans.
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This material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. References to third party sources or organizations are not a representation, warranty or endorsement of such organizations. Any questions regarding those organizations should be addressed to them directly.