Aetna considers hepatitis B vaccine a medically necessary preventive service for members with any of the following indications:
Infants, regardless of hepatitis B surface antigen (HBsAg) status of the mother; or
Children and adolescents (0 to 18 years) who have not been vaccinated previously; or
Adults (over 18 years of age) at increased risk for hepatitis B infection, including:
Transplant candidates of any age.
Aetna considers hepatitis B vaccine experimental and investigational for all other indications because its effectiveness for indications other than the ones listed above has not been established.
Booster doses of Hepatitis B vaccine are considered medically necessary only in certain circumstances:
This policy is consistent with CDC guidelines.
*Note: Aetna generally does not cover immunizations required for travel or because of work-related risk. Check contract language, limitations and exclusions for coverage details.Background
Pre-exposure immunization of susceptible persons with hepatitis B vaccine is the most effective means to prevent hepatitis B virus (HBV) transmission. To reduce transmission of HBV and eventually to eliminate it, universal immunization is necessary. Vaccination against HBV has been recommended as part of routine early childhood immunizations since 1991. Accordingly, immunization of all children before or during adolescence is necessary and recommended. Along with universal immunization efforts, immunization of adults belonging to identified high-risk groups is appropriate. Post-exposure evaluation and treatment, including diagnostic testing and immunization in selected cases, is also appropriate to prevent HBV infection among individuals of all ages regardless of the presence or absence of risk factors.
These indications blend the recommendations of the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). These 3 groups, working with federal agencies, have approved a unified childhood immunization schedule. The recommendations for hepatitis B vaccine in the unified schedule are generally similar to those recommended by the U.S. Preventive Services Task Force (USPSTF). However, routine hepatitis B vaccine was recommended only in infancy in the unified schedule, whereas the USPSTF also recommends its routine use in all children and adolescents not previously immunized. The ACIP and AAP have subsequently revised their recommendations for hepatitis B vaccine to include all children aged 11 to 12 years who have not previously been vaccinated; ACIP also recommends vaccinating unimmunized children under 11 years who are Pacific Islanders or who reside in households of first-generation immigrants from countries with high or intermediate HBV endemicity.
Three doses of hepatitis B vaccine are required for complete immunization. For infants, the Centers for Disease Control and Prevention (CDC) and the ACIP recommend hepatitis B vaccine be incorporated into the routine vaccination schedules for children.
Hepatitis B vaccine has been administered using an accelerated immunization protocol for persons who are candidates for solid organ, bone marrow or stem cell transplantation to reduce the risk of hepatitis infection from administration of blood products and transplanted organs.
The annual recommended childhood and adolescent immunization schedule for January to December 2006 approved by the AAP, the ACIP of the CDC, and the AAFP (2006) states that vaccination of infants born to HBsAg-negative mothers can be delayed in rare circumstances, but only if a physician's order to withhold the vaccine and a copy of the mother's original HBsAg-negative laboratory report are documented in the infant's medical record. Administering 4 doses of HepB is permissible (e.g., when combination vaccines are administered after the birth dose); however, if monovalent HepB is used, a dose at age 4 months is not needed. For infants born to HBsAg-positive mothers, testing for HBsAg and antibody to HBsAg after completion of the vaccine series should be conducted at age 9 to18 months (generally at the next well-child visit after completion of the vaccine series).
In a randomized controlled trial (RCT), Cornejo-Juarez et al (2006) found that an increase dose of HBV vaccine did not increase the rate of response in HIV infected subjects. These researchers assessed 2 doses of recombinant HBV vaccine (10 or 40 microg), intra-muscular (IM) at 0, 1 and 6 months. Vaccination response was measured 30 to 50 days after last dose; titers of greater than 9.9 IU/L were considered positive. A total of 79 patients were included, 48 patients (60.7 %) sero-converted. Thirty-nine patients (49.3 %) received 10 microg vaccine dose, 24 patients (61.5 %) sero-converted. Forty patients (50.7 %) received 40 microg vaccine dose, 24 (60 %) sero-converted. There were no differences between the 2 doses. A statistically significant higher sero-conversion rate was found for patients with CD4 cell counts at vaccination greater than or equal to 200 cell/mm3 (33 of 38 patients, 86.8 %), compared with those with CD4 less than 200 cell/mm3 (15 of 41, 36.6 %), (odds ratio of 11.44, 95 % confidence interval [CI]: 3.67 to 35.59, p = 0.003), there were no differences between 2 vaccine doses. Using the logistic regression model, CD4 count less than 200 cell/mm3 were significantly associated with non-serological response (p = 0.003). None other variables such as gender, age, risk exposure for HIV, viral load, type or duration of highly active anti-retroviral therapy or AIDS-defining illness, were associated with sero-conversion. The authors concluded that an increase dose of HBV vaccine did not show to increase the rate of response in HIV infected subjects. The only significant findings associated to the response rate was that a CD4 count greater than or equal to 200 cell/mm3, these investigators suggested this threshold at which HIV patients should be vaccinated.
Pasricha and colleagues (2006) evaluated the effectiveness of recombinant vaccine in treatment-naive HIV-positive patients and healthy controls, and ascertained differences if any, in different limbs of immune response. A total of 40 HIV-positive patients and 20 HIV-negative controls, negative for HBsAg, HBsAbs and HBcAbs were vaccinated with 3 doses of 40 microg and 20 microg of vaccine, respectively. Patients were divided into high-CD4 and low-CD4 group based on CD4+ lymphocytes of 200 and less than 200/mm3, respectively. Group II consisted of healthy controls. Detection of phenotypic markers was done by flow cytometry. Cytokine estimation was done by sandwich ELISA. HBsAbs were estimated in serum by ELISA. After vaccination, CD4+, CD8+ and CD3+ cells increased significantly in all the groups. There was no increase in natural killer cell activity in patients with high CD4+ lymphocytes and only a marginal increase in patients with low CD4+ lymphocytes (170 to 293/mm3) whereas a marked increase was observed in controls (252 to 490/mm3). After vaccination, although an increase in memory cells was observed in HIV-positive patients, yet HBsAb levels were significantly lower than controls (p < 0.05) indicating a functional defect of memory cells in HIV/AIDS patients. Basal interferon-gamma levels were also significantly lower in HIV/AIDS patients (p < 0.01). Although the levels increased after vaccination, the peak level remained lower than in controls. HBsAb titers were much lower in HIV-positive patients compared to controls. (high-CD4+ group: 8834 mIU/ml, low-CD4+ group: 462 mIU/ml versus controls: 16,906 mIU/ml). IL-4 and IL-10 were low in patients. The authors concluded that despite a double dose in patients, IL-4 and IL-10, which regulate antibody response, were also lower in patients, and this together with low CD4+ counts and lack of T help, accounted for low HBsAb levels. Vaccination in patients with CD4+ lymphocytes less than 50/mm3 was ineffective.
It is also interesting to note that extended double-dosage HBV vaccination (2 cycles of 3 IM double doses [40 microg], given at month 0, 1, 2, and 3, 4, 5) following liver transplantation is ineffective (Di Paolo et al, 2006).
In a Cochrane review on hepatitis B immunization in persons not previously exposed to hepatitis B or with unknown exposure status, Mathew and colleagues (2008) concluded that in people not previously exposed to hepatitis B, vaccination has unclear effect on the risk of developing infection, as compared to no vaccination. The risk of lacking protective antibody levels as well as serious and non-serious adverse events appear comparable among recipients and non-recipients of hepatitis B vaccine.
According to the CDC, pregnancy is not a contraindication to hepatitis B vaccination. The CDC states that limited data indicate no apparent risk for adverse events to developing fetuses when hepatitis B vaccine is administered to pregnant women. Current vaccines contain noninfectious HBsAg and should cause no risk to the fetus. The CDC states that pregnant women who are identified as being at risk for HBV infection during pregnancy (e.g., having more than 1 sex partner during the previous 6 months, been evaluated or treated for an sexually transmitted disease, recent or current injection drug use, or having had an HBsAg-positive sex partner) should be vaccinated.
Lin and Vickery (2009) searched for large, high-quality studies related to hepatitis B screening in pregnancy that have been published since the 2004 USPSTF recommendation. English-language studies indexed in PubMed and the Cochrane Database of Systematic Reviews and published between January 1, 2001 and March 5, 2008 were included in this study. For benefits of screening and newborn prophylaxis, these investigators included systematic reviews; meta-analyses; and RCTs. For harms of screening, they included systematic reviews; meta-analyses; RCTs; cohort studies; case-control studies; and case series of large, multi-site databases. Abstracts and full articles were independently reviewed for inclusion by both reviewers. Data on the benefits of screening, including benefits of hepatitis B immune globulin and hepatitis B vaccine prophylaxis of newborns of HBsAg-positive mothers, were extracted by 1 reviewer. No new studies met inclusion criteria. A 2006 systematic review of RCTs found that newborn prophylaxis reduced peri-natal transmission of HBV infection; all relevant trials were published in 1996 or earlier. The authors concluded that no new evidence was found on the benefits or harms of screening for HBV infection in pregnant women. Previously published RCTs support the 2004 USPSTF recommendation for screening.
In a Cochrane review, Poorolajal et al (2010) evaluated the benefits and harms of booster dose hepatitis B vaccination for preventing hepatitis B infection. Randomized clinical trials addressing anamnestic immune response to booster of hepatitis B vaccine 5 years or more after primary vaccination in apparently healthy participants, vaccinated in a 3-dose or 4-dose schedules of hepatitis B vaccine without receiving additional dose or immunoglobulin were included in this analysis. Two authors made the decisions if the identified publications on studies met the inclusion criteria or not. Primary outcome measures included the proportion with anamnestic immune response in non-protected participants and signs of HBV infection. Secondary outcomes were the proportion with local and systemic adverse event events developed following booster dose injection. Weighted proportion were planned to be reported with 95 % confidence interval. There were no eligible RCTs fulfilling the inclusion criteria of this review. The authors were unable to identify RCTs on the topic. They stated that there is a need for RCTs to formulate future booster policies for preventing HBV infection.
In a Cochrane review, Sangkomkamhang and colleagues (2011) evaluated the effectiveness and adverse effects of hepatitis B vaccine administered to pregnant women for preventing HBV infection in infants. Randomized controlled trials assessing hepatitis B vaccination compared with placebo or no treatment during pregnancy for preventing infant infection were included in this analysis. These investigators excluded quasi-RCTs and cross-over studies. Two review authors independently assessed trial eligibility. They were not able to include any studies. The authors found no RCTs that assessed the effects of hepatitis B vaccine during pregnancy for preventing infant infection. Consequently, this review can not provide guidance for clinical practice in this area. However, it does identify the need for well-designed RCTs for the effect of hepatitis B vaccine during pregnancy on the incidence of infant infection and adverse effects.
On the basis of available information about HBV risk, morbidity and mortality, available vaccines, age at diagnosis of diabetes, and cost-effectiveness, the ACIP (2011) recommended the following:
Fabrizi et al (2012) stated that patients with chronic kidney disease typically show an impaired immune response to HBV vaccine compared with healthy individuals. A variety of inherited or acquired factors have been implicated in this diminished response. Some authors suggested a benefit with adjuvantation to improve the immunogenicity of existing HBV vaccines. In a meta-analysis, these investigators evaluated the safety and effectiveness of adjuvantation for HBV vaccine in patients with chronic kidney disease. Only prospective, RCTs were included. These researchers used the random effects model of DerSimonian and Laird with heterogeneity and subgroups analyses. The primary end-point of interest was the sero-protection rate after HBV vaccination with recombinant vaccine plus adjuvants (study group) versus recombinant vaccine alone (control group). These investigators identified 10 studies involving 1,228 unique patients with chronic kidney disease. Pooling of study results did not show a significant increase in sero-protection rate among study (HBV recombinant vaccine plus adjuvants) versus control (HBV recombinant alone) patients; the pooled odds ratio (OR) of sero-protection rate was 1.47 (95 % CI: 0.88 to 2.46, NS). The pooled OR for sero-response rate after HBV vaccine (adjuvanted recombinant vaccine versus recombinant vaccine alone) did not change in the subgroup of studies based on novel adjuvant systems (i.e., HBV-AS04 or HBV-AS02), the pooled OR was 2.22 (95 % CI: 0.72 to 6.78), NS. Q-test for heterogeneity being 10.819 (p = 0.004). The authors concluded that this meta-analysis showed that adjuvanted hepatitis B vaccine did not significantly improve the sero-protection rate in patients with renal insufficiency. These results do not support adjuvantation as an approach to increase the immunogenicity of existing recombinant vaccines towards HBV in this high-risk population.
Cui and colleagues (2013) evaluated the associations between functional polymorphisms in the interleukin-4 (IL4) gene and individuals' responses to hepatitis B vaccine and their susceptibility to HBV infection. A literature search on articles published before December 1st, 2012 was conducted in PubMed, Embase, Web of Science and China BioMedicine (CBM) databases. Crude ORs with 95 % CIs were calculated. Statistical analyses were performed using the STATA 12.0 software. A total of 8 studies were eligible for inclusion in this meta-analysis, including 5 cross-sectional studies on individual's response to hepatitis B vaccine and 3 case-control studies on HBV infection risk. The meta-analysis results showed that the T allele of rs2243250, the T allele of rs2070874, and the C allele of rs2227284 in IL4 gene were associated with high responses to hepatitis B vaccine. Further subgroup analysis by ethnicity showed that there was a significant association between IL4 genetic polymorphisms and an individual's responses to hepatitis B vaccine among Asian populations, but similar association was not found among Caucasian populations. However, there was no evidence indicating a correlation between IL4 genetic polymorphism and susceptibility to HBV infection. The authors concluded that the findings of this meta-analysis suggested that rs2243250, rs2070874 and rs2227284 polymorphisms in IL4 gene may play an important role in determining the response to hepatitis B vaccine, especially among Asian populations. However, they stated that further studies are still needed to evaluate the associations between IL4 genetic polymorphisms and HBV infection risk.
Zhang et al (2014) noted that combined immunization with hepatitis B immunoglobulin (HBIG) plus hepatitis B vaccine (HB vaccine) can effectively prevent peri-natal transmission of hepatitis B virus (HBV). With the universal administration of HB vaccine, anti-HBs conferred by HB vaccine can be found increasingly in pregnant women, and maternal anti-HBs can be passed through the placenta. These researchers evaluated the effect of hepatitis B immunization on preventing mother-to-infant transmission of HBV and on the immune response of infants towards HB vaccine. From 2008 to 2013, a prospective study was conducted in 15 centers in China. HBsAg-positive pregnant women and their infants aged 8 to 12 months who completed immunoprophylaxis were enrolled in the study and tested for HBV markers (HBsAg, anti-HBs, HBeAg, anti-HBe and anti-HBc). Ante-partum administration of HBIG to HBsAg-positive women was based on individual preference. HBsAg-negative pregnant women and their infants of 7 to 24 months old who received HB vaccines series were enrolled and tests of their HBV markers were performed. A total of 1,202 HBsAg-positive mothers and their infants aged 8 to 12 months were studied and 40 infants were found to be HBsAg positive with the immunoprophylaxis failure rate of 3.3 %. Infants with immunoprophylaxis failure were all born to HBeAg-positive mothers of HBV-DNA greater than or equal to 6 log₁₀copies/ml. Among infants of HBeAg-positive mothers, immunoprophylaxis failure rate in vaccine plus HBIG group, 7.9 % (29/367), was significantly lower than the vaccine-only group, 16.9 % (11/65), p = 0.021; there was no significant difference in the immunoprophylaxis failure rate whether or not antepartum HBIG was given to the pregnant woman, 10.3 % (10/97) versus 9.0 % (30/335), p = 0.685. Anti-HBs positive rate was 56.3 % (3,883/6,899) among HBsAg-negative pregnant women and anti-HBs positive rate was 94.2 % in cord blood of anti-HBs-positive mothers. After completing the HB vaccine series, anti-HBs positive rate among infants with maternal anti-HBs titers of less than 10 IU/L, 10 to 500 IU/L and greater than or equal to 500 IU/L was 90.3 % (168/186), 90.5 % (219/242) and 80.2 % (89/111), respectively, p = 0.011. Median titers of anti-HBs (IU/L) among infants in the 3 groups was 344.2, 231.9 and 161.1, respectively, p = 0.020. The authors concluded that HBIG plus HB vaccine can effectively prevent mother-to-infant transmission of HBV, but no HBV breakthrough infection was observed in infants born to HBeAg-negative mothers who received HB vaccine with or without HBIG after birth. They stated that ante-partum injection of HBIG has no effect on preventing HBV mother-to-infant transmission; high maternal titer of anti-HBs can transplacentally impair immune response of infants towards HB vaccine.
Machaira et al (2015) stated that the cost-effectiveness of augmenting immunization against hepatitis B infection with HBIG remains controversial, particularly for the subpopulation of babies of HBsAg+/HBeAg- mothers that are considered as low-infective. These researchers evaluated the effectiveness of vaccine alone compared with vaccine plus HBIG for the immunization of babies of HBsAg+/HBeAg- mothers. They searched PubMed, Scopus and Cochrane Central Register of Controlled Trials databases to identify studies comparing the effectiveness of combined immunization (vaccine plus HBIG) with vaccine alone in neonates of HBsAg+/HBeAg- mothers. A systematic review and meta-analysis of eligible studies was performed. A total of 9 eligible studies were identified (4 RCTs). No difference was found regarding the primary outcome of this meta-analysis, namely occurrence of hepatitis B infection, between neonates who received vaccine only, compared with those who received both vaccine and HBIG (4 studies, 3,426 patients, OR = 0.82, 95 % CI: 0.41 to 1.64). This finding was consistent with regards to sero-protection rate (4 studies, 1,323 patients, OR = 1.24, 95 % CI: 0.97 to 1.58). Safety data were not reported in the included studies. The authors concluded that available limited published evidence suggested that vaccine alone seems to be equally effective to the combination of HBIG and hepatitis B vaccine for neonates of HBsAg+/HBeAg- mothers in preventing infection. They stated that further studies are needed in order to clarify the potential benefit of combined immunization to this specific subgroup of patients.
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|90739 - 90748, 90636||Hepatitis B vaccine|
|HCPCS codes covered if selection criteria are met:|
|G0010||Administration of hepatitis B vaccine|
|ICD-10 codes covered if selection criteria are met:|
|A50.01 - A64||Infections with a predominantly sexual mode of transmission|
|B17.10 - B17.11
B19.20 - B19.21
|B20||Human immunodeficiency virus [HIV] disease|
|B97.35||Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere|
|D65 - D68.9||Coagulation defects [hemophiliacs]|
|D69.1||Qualitative platelets defects|
|E08.00 - E13.9||Diabetes mellitus|
|F11.10 - F19.99||Drug dependence and nondependent abuse of drugs [injecting-drug users]|
|K70.0 - K70.9
K73.0 - K73.9
K74.0 - K74.69
K76.0 - K76.1
K76.81 - K76.9
|Chronic liver diseases and cirrhosis|
|Z00.110||Health examination for newborn under 8 days old|
|Z00.111||Health examination for newborn 8 to 28 days old|
|Z00.121||Encounter for routine child health examination with abnormal findings|
|Z00.129||Encounter for routine child health examination without abnormal findings|
|Z00.3||Encounter for examination for adolescent development state|
|Z02.0||Encounter for examination for admission to educational institution [school children age 0-18]|
|Z02.1||Encounter for pre-employment examination [healthcare workers]|
|Z02.2||Encounter for examination for admission to residential institution [students]|
|Z02.89||Encounter for other administrative examination [admission to prison]|
|Z20.5||Contact with and (suspected) exposure to viral hepatitis|
|Z21||Asymptomatic human immunodeficiency virus [HIV] infection status|
|Z22.4||Carrier of infections with a predominantly sexual mode of transmission|
|Z22.50 - Z22.59||Carrier of viral hepatitis|
|Z23||Encounter for immunization|
|Z51.11||Encounter for antineoplastic chemotherapy|
|Z72.51 - Z72.53||High risk sexual behavior [history of multiple sex partners]|
|Z76.82||Awaiting organ transplant status|
|Z94.0||Kidney transplant status|
|Z94.1||Heart transplant status|
|Z94.2||Lung transplant status|
|Z94.3||Heart and lung transplant status|
|Z94.4||Liver transplant status|
|Z94.6||Bone transplant status|
|Z94.81||Bone marrow transplant status|
|Z94.82||Intestine transplant status|
|Z94.83||Pancreas transplant status|
|Z94.84||Stem cells transplant status|
|Z94.89 - Z94.9||Other and unspecified transplanted organ and tissue status|
|Z99.2||Dependence on renal dialysis|