Aetna considers polio vaccine a medically necessary preventive service for members according to the recommendations of the Centers for Disease Control and Prevention's (CDC) Advisory Committee for Immunization Practices (ACIP).
The ACIP recommends an injectable polio vaccine (IPV) schedule (as opposed to an oral vaccine schedule) for routine childhood polio vaccination in the United States to eliminate the risk for vaccine-associated paralytic polio (VAPP). The schedule recommends that all children should receive four doses of IPV at ages 2 months, 4 months, 6-18 months, and 4-6 years. They recommend the use of oral polio vaccine (OPV) only for the following special circumstances:
Mass vaccination campaigns to control outbreaks of paralytic polio; or
Unvaccinated children who will be traveling in less than 4 weeks to areas where polio is endemic; or
Children of parents who are not willing to have their child have the recommended injectable form of vaccine. These children may be given OPV only for the third or fourth dose or both. In this situation, health-care providers should administer OPV only after discussing the risk of VAPP with parents or caregivers.
Polio vaccine is also recommended for adults (greater than 18 years of age) who are at increased risk of exposure to poliovirus including:
Travelers to areas where poliomyelitis is endemic or epidemic,*
Laboratory workers handling specimens which may contain polioviruses,*
Health-care workers in close contact with individuals who may be excreting wild polioviruses,* and
Individuals who are members of specific population groups currently supervening an outbreak of polio caused by wild polioviruses.
For adults at increased risk of exposure to poliomyelitis, primary immunization with IPV is recommended. The recommended schedule for adults is two doses given at 1-2 month intervals, and a third dose given 6-12 months later.
*Note: Some Aetna plans exclude coverage of immunizations required for travel or because of work related risk. Please check benefit plan descriptions for details.
Background
Poliomyelitis is a viral disease that causes inflammation of the gray matter of the spinal cord. Infection causes fever, pains, and gastroenteric disturbances in the acute stage, followed by a flaccid paralysis of one or more muscular groups, which is later followed by atrophy. Since 1979, the only indigenous cases of poliomyelitis reported in the United States have been associated with the use of OPV. OPV can cause polio (one case per 2.4 million doses distributed) because it contains live, but weakened, virus. Until recently, the benefits of OPV use (i.e., intestinal immunity, secondary spread) outweighed the risk for VAPP. Widespread childhood vaccination has led to the complete eradication of wild-type poliovirus infection in the United States.
Inactivated poliovirus vaccine may be given concurrently with other vaccines. If IPV and DTaP or DTP are given at the same time, they should be administered in separate syringes because of possible interference. An investigational, dual-chambered syringe that allows mixing of selective DTP or DTaP and IPV preparations just before injection has been developed.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
90698
90712
90713
90723
ICD-9 codes covered if selection criteria are met:
V01.2
Contact with or exposure to poliomyelitis
V04.0
Need for prophylactic vaccination and inoculation against poliomyelitis
V06.3
Need for prophylactic vaccination and inoculation against Diptheria-tetanus-pertussis with poliomyelitis [DTP + polio]
Other ICD-9 codes related to the CPB:
045.00 - 045.93
Acute poliomyelitis
The above policy is based on the following references:
Centers for Disease Control and Prevention (CDC). Recommendations of the Advisory Committee on Immunization Practices: Revised recommendations for routine poliomyelitis vaccination. MMWR Morb Mortal Wkly Rep. 1999;48(27):590.
American Academy of Pediatrics, Committee on Infectious Diseases. Prevention of poliomyelitis: Recommendations for use of only inactivated poliovirus vaccine for routine immunization. Pediatrics. 1999;104(6):1404-1406.
American Academy of Pediatrics, Committee on Infectious Diseases. 2003 Red Book: Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003.
U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. Report of the U.S. Preventive Services Task Force. 2nd ed. Baltimore, MD: Williams & Wilkins; 1996.
Gardner P, Peter G. Recommended schedules for routine immunization of children and adults. Infect Dis Clin North Am. 2001;15(1):1-8.
Centers for Disease Control and Prevention (CDC), National Center for Infectious Diseases, National Immunization Program. Poliomyelitis. In: Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book. Waldorf, MD: The Public Health Foundation; April 2002; Ch. 7: 71-82.
Atkinson WL, Pickering LK, Schwartz B, et al. General recommendations on immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP). MMWR Recomm Rep. 2002;51(RR-2):1-35.
Machado CM. Reimmunization after bone marrow transplantation--current recommendations and perspectives. Braz J Med Biol Res. 2004;37(1):151-158.
Khan MM, Ehreth J. Costs and benefits of polio eradication: A long-run global perspective. Vaccine. 2003;21(7-8):702-705.
Vergara R, Tregnaghi M, Ussher J, et al. Reduced-antigen-content-diphtheria-tetanus-acellular-pertussis and inactivated polio vaccine as a booster for adolescents 10 to 14 years of age. Eur J Pediatr. 2005;164(6):377-382.
Grimprel E, von Sonnenburg F, Sanger R, et al. Combined reduced-antigen-content diphtheria-tetanus-acellular pertussis and polio vaccine (dTpa-IPV) for booster vaccination of adults. Vaccine. 2005;23(28):3657-3667.
Patel SR, Ortin M, Cohen BJ, et al. Revaccination of children after completion of standard chemotherapy for acute leukemia. Clin Infect Dis. 2007;44(5):635-642.
Chumakov K, Ehrenfeld E, Wimmer E, Agol VI. Vaccination against polio should not be stopped. Nat Rev Microbiol. 2007;5(12):952-958.
Black S, Friedland LR, Ensor K, et al. Diphtheria-tetanus-acellular pertussis and inactivated poliovirus vaccines given separately or combined for booster dosing at 4-6 years of age. Pediatr Infect Dis J. 2008;27(4):341-346.
Weston WM, Klein NP. Kinrix: A new combination DTaP-IPV vaccine for children aged 4-6 years. Expert Rev Vaccines. 2008;7(9):1309-1320.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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