Clinical Policy Bulletin: Immune Globulins for Post-exposure Prophylaxis
Number: 0544
Policy
Hepatitis A Immune Globulin:
Aetna considers hepatitis A immune globulin medically necessary for members who are exposed or likely to be exposed to hepatitis A virus (HAV). Risk groups include household and sexual contacts of persons with hepatitis A, newborn infants of HAV-infected mothers, staff* and children at child-care centers and schools with HAV outbreaks, staff* of custodial care institutions with HAV outbreaks, and individuals exposed to HAV through food or waterborne outbreaks. Hepatitis A immune globulin is considered experimental and investigational for other indications.
Hepatitis B Immune Globulin:
Aetna considers hepatitis B immune globulin medically necessary for members who have had contact with an individual diagnosed with hepatitis B virus (HBV). Risk groups include infants born to hepatitis B surface antigen (HBsAg) positive mothers, persons with percutaneous or permucosal exposure to HbsAg-positive blood, sexual contacts of HbsAg-positive persons, and household exposure of infants less than 1 year of age to a primary caregiver with acute HBV infection.
Prolonged use of hepatitis B immune globulin is considered medically necessary for prophylaxis of recurrent hepatitis B infection in HbsAg positive liver transplant recipients. Hepatitis B immune globulin is considered experimental and investigational for other indications.
Cytomegalovirus Immune Globulin:
Aetna considers cytomegalovirus (CMV) immune globulin medically necessary for members who have had definite symptoms or exposure to cytomegalovirus. Cytomegalovirus immune globulin is also considered medically necessary for prophylaxis or treatment of cytomegalovirus disease in CMV-negative renal transplant members receiving a CMV-positive donor organ, and for prophylaxis and treatment of CMV disease in other transplant recipients.
Aetna considers the use of CMV immune globulin experimental and investigational for all other indications, including use in prophylaxis of persons with IgA deficiency or Waldenstrom's macroglobulinemia.
Aetna considers Rho-D Immune Globulin (e.g., Gamulin Rh, HypRho-D Full Dose, HypRho-D Mini-Dose, MICRhoGAM, Mini-Gamulin Rh, Rhogam, and WinRho SDF) medically necessary for preventing hemolytic disease of the newborn. Rho-D immune globulin is considered medically necessary for all unsensitized Rh-negative women at 24-28 weeks gestation, unless the father is known to be Rh-negative. A repeat postpartum dose is considered medically necessary if a Rh-positive infant is delivered. Administration of Rho-D immune globulin is considered medically necessary in unsensitized Rh-negative women, unless the father is known to be Rh-negative, after other obstetric complications such as amniocentesis, chorionic villus sampling, ectopic pregnancy, pregnancy termination (including elective abortion), cordocentesis, fetal surgery or manipulation (including external version), antepartum placental hemorrhage, antepartum fetal death, miscarriage and stillbirth. Rho-D immune globulin is also considered medically necessary for treatment of Rho-D positive persons with idiopathic thrombocytopenic purpura. Rho-D immune globulin is considered experimental and investigational for other indications.
Rabies Immune Globulin:
Aetna considers rabies immune globulin medically necessary for treatment of rabies exposure where the animal has escaped or is known to be rabid at the time of direct exposure or attack*. Rabies immune globulin is considered experimental and investigational for other indications.
Varicella Zoster (Chickenpox) Immune Globulin:
Aetna considers varicella zoster immune globulin (VZIG) medically necessary for prevention of varicella (chickenpox) infections in high-risk individuals who have significant exposure to the disease due to contact with an individual who is infected with varicella (chickenpox), according to recommendations of the American Academy of Pediatrics. High risk individuals include immunocompromised persons without a history of chickenpox, susceptible pregnant women, newborn infants whose mother had onset of chickenpox within the 5 days before delivery or within 48 hours after delivery, hospitalized premature infants 28 or more weeks gestation whose mother has no history of chickenpox, and hospitalized premature infants less than 28 weeks gestation regardless of maternal history. Significant exposures include household contacts of infected persons, face-to-face indoor play with infected persons, hospital contact with infected persons, and newborn infants whose mothers had onset of chickenpox near time of delivery (described above). VZIG is considered experimental and investigational for other indications.
Tetanus Immune Globulin:
Aetna considers intramuscular injection of tetanus immune gamma globulin medically necessary for prevention of tetanus in non-immunized persons, incompletely immunized persons (who have not completed the 3-dose primary vaccination series), and remotely immunized persons (last complete vaccination more than 10 years agoe) with neglected or tetanus-prone wounds (contaminated, necrotizing, or puncture wounds)*. Tetanus immune globulin is considered experimental and investigational for other indications.
Rubeola (Measles) Immune Globulin:
Aetna considers intramuscular injection of measles (rubeola) immune globulin medically necessary for unvaccinated individuals exposed to the disease. Aetna considers rubeola immune globulin experimental and investigational for other indications.
Immune Globulin (IVIG) for German Measles (Rubella):
Aetna considers nonspecific intravenous immune globulin (IVIG) medically necessary for non-immune women with documented exposure to rubella during the first trimester (3 months) of pregnancy.
Respiratory Syncytial Virus (RSV) Immune Globulin or Palivizumab:
Aetna considers vaccinia vaccine medically necessary for treatment of vaccine complications with severe clinical manifestations (e.g., eczema vaccinatum, progressive vaccinia, severe generalized vaccinia, and severe ocular viral implantation).* Aetna considers vaccinia immune globulin experimental and investigational for other indications. See also CPB 644 - Smallpox Vaccine.
*Note: Treatment of work-related injuries is excluded from coverage under some benefit plans. Please check benefit plan descriptions. Work-related injuries may be covered by the employer's workman's compensation benefit plan.
Background
Cytomegalovirus Immune Globulin
Cytomegalovirus Immune Globulin IV (CMV-Ig) is an injectable product which contains antibodies directed specificially towards cytomegalovirus (CMV). CMV is generally present in persons who have been exposed to the virus. While CMV is quite prevalent in adults and is typically benign in healthy people, it is a significant cause of morbidity and mortality in people who are immunosuppressed due to organ transplantation or AIDS.
Cytomegalovirus Immune Globulin IV is currently FDA approved for use in prevention and attentuation of cytomegalovirus disease in renal transplant patients. It also has been shown to be beneficial in prevention and treatment of cytomegalovirus disease in patients who have received an orthotopic liver transplant. There is also evidence for use of CMV-Ig in other solid organ transplants (such as heart and lung) and in bone marrow transplants.
Studies in renal transplantation have generally been limited to patients who are CMV seronegative; use in seropositive recipients therefore remains investigational. This is not the case with other transplants; in fact, results in liver transplant patients have shown a decrease in severe CMV-associated syndromes.
Hepatitis B Immune Globulin
Hepatitis B immune globulin is appropriate when used to provide passive immunization to hepatitis B as prophylaxis for certain exposed individuals. The Advisory Committee on Immunization Practices states that combined passive and active immunization is preferred to passive immunization with HBIg alone in neonates born to HBsAb-positive women, in individuals exposed percutaneously or by ingestion or mucous membrane contact, and in individuals bitten by human carriers of HBsAG. Also, combined treatment is recommended for patients exposed through sexual contact. Hepatitis B immune globulin is administered promptly after exposure and again in one month.
Hepatitis B immune globulin is also indicated for prophylaxis of recurrent hepatitis B infection in HbsAg positive liver transplant recipients. Hepatitis B immune globulin prophylaxis is administered on a lifelong or indefinite basis for this indication.
The manufacturers state that the IM product is not to be used intravenously). This is apparently because "serious systemic allergic reactions could occur following inadvertent IV administration of HBIg, since such reactions have occurred following IV administration of immune globulin". Since it appears that the contraindication to IV use is theoretical, and that IV use is occurring without safety problems, it is appropriate to allow IV use when IM is not an option.
Hepatitis A Immune Globulin
Hepatitis A immune globulin is indicated for persons who are exposed or likely to be exposed to hepatitis A virus (HAV). Risk groups include household and sexual contacts of persons with hepatitis A, newborn infants of HAV-infected mothers, staff and children at child-care centers and schools with HAV outbreaks, staff of custodial care institutions with HAV outbreaks, and individuals exposed to HAV through food or waterborne outbreaks. The usual dose is a single intramuscular injection administered within two weeks of exposure.
Rho-D Immune Globulin
Rhogam is a specially prepared immune globulin injected into an Rh-negative mother to prevent Rh hemolytic disease in future children. Rho-D immune globulin may be indicated for prevention of Rh hemolytic disease in neonates by administration to selected premenopausal, Rho-D negative females; and for treatment of selected Rho-D-positive patients with ITP.
Administration of Rhogam is recommended under generally accepted guidelines for all unsensitized Rh-negative women at 24-28 weeks gestation, unless the father is known to be Rh-negative. If a Rh-positive infant is delivered, accepted guidelines indicate the dose should be repeated postpartum, preferably within 72 hours of delivery. The American College of Obstetricians and Gynecologists recommends administration of Rhogam after other obstetric complications such as amniocentesis, chorionic villus sampling, ectopic pregnancy, pregnancy termination, cordocentesis, fetal surgery or manipulation (including external version), antepartum placental hemorrhage, antepartum fetal death, miscarriage and stillbirth. The literature indicates this immune globulin may also be used for treatment of selected Rho-D positive persons with idiopathic thrombocytopenic purpura. Under generally accepted guidelines, Rhogam is recommended for all unsensitized Rh-negative women after elective abortion, unless the father is known to be Rh-negative.
WinRho may be administered intramuscularly or intravenously over 3-5 minutes. Other brands are indicated for intramuscular use. Intramuscular injection is a relative contraindication in patients with ITP; however, has been used with some success. While some feel that use of this product for treatment of ITP may not be effective in splenectomized patients, others provide evidence to the contrary.When given in conjunction with pregnancy, Rho-D immune globulin does not provide benefit for the infant from that pregnancy. Its use is intended to prevent Rh hemolytic disease in future infants born to that mother.
Varicella Zoster Immune Globulin
Varicella zoster immune globulin (VZIG) is considered appropriate when used to prevent varicella (chickenpox) infection as recommended by the Advisory Committee on Immunization Practices (ACIP). According to the ACIP, VZIG is necessary, provided that significant exposure has occurred for immunocompromised children without a history of chickenpox. Immuocompromised adolescents and adults are likely to be immune, but if susceptible, should also receive VZIG. VZIG is also necessary, provided that significant exposure has occurred, for the following groups; susceptible pregnant women; newborn infants whose mother had onset of chickenpox within the 5 days before delivery or within the 48 hours after delivery; hospitalized premature infants (greater than or equal to 28 weeks gestation) whose mother has no history of chickenpox; and hospitalized premature infants (less than 28 wk gestation or less than or equal to 1,000 grams) regardless of maternal history.
VZIG may be indicated in the above listed susceptible groups if significant exposure to varicella has occurred in the hospital: in the same 2- to 4-bed room, or adjacent beds in a large ward; face-to-face contact with an infectious staff memeber or patient, or visit by a person deemed contageous. Experts differ in the duration of face-to-face contact that warrants the administration of VZIG. Some experts suggest a contact of 5 or more minutes as constituting significant exposure for this purpose; others define close contact as more than one hour. In any case, the face-to-face contact should be nontransient to be considered significant.
Other types of exposure for which VZIG is indicated in the above listed susceptible groups include: household exposure (residing in the same household); exposure from playmates (face-to-face indoor play); and intimate contact with zoster lesions (e.g., touching or hugging a person deemed contageous; and exposure of newborn infant (onset of varicella in the mother 5 days or less before delivery or within 48 hours after delivery; VZIG is not indicated if the mother has zoster). The ACIP recommends that VZIG be administered within 96 hours of exposure
Laboratory determination of susceptibility to varicella is sometimes impractical. Because of this, the ACIP recommends that determination of susceptibility be based on a carefully obtained history of prior infection or exposure. However, in the case of pregnant women, serologic status should be determined through immunofluorescent assay or ELISA test if results can be available within 96 hours of exposure. If this test is feasible and negative, immune globulin need not be given. Otherwise, pregnant women should be considered susceptible.
Varicella zoster immune globulin is not necessary in individuals who are considered to be immune to varicella zoster.With the exception of bone marrow transplant recipients, individuals considered to be immune to varicella zoster include those with a history of they have prior varicella infection, or negative or uncertain exposure if they are at least 15 years of age and immunocompetent.In addition, patients with a history of infection with varicella or herpes zoster subsequent to bone marrow transplant are considered to be immune.
There is currently no evidence that administration of VZIG to pregnant women during the first or second trimester of pregnancy will prevent congenital varicella syndrome or that administration during the third trimester will prevent neonatal varicella. In addition, postexposure administration of VZIG in susceptible, pregnant women may prevent or suppress clinical disease in the mother without preventing fetal infection or disease. For this reason, administration of VZIG for pregnant women who do not fit the criteria listed above is not considered to be necessary.
Vaccinia (Smallpox) Immune Globulin
Vaccinia vaccine is indicated for treatment of vaccine complications with severe clinical manifestations (e.g., eczema vaccinatum, progressive vaccinia, severe generalized vaccinia, and severe ocular viral implantation). See CPB 644 -- Smallpox vaccine. The only product currently available for treatment of complications of vaccinia vaccination is vaccinia immunoglobulin, which is an isotonic sterile solution of the immunoglobulin fraction of plasma from persons vaccinated with vaccinia vaccine. It is effective for treatment of eczema vaccinatum and certain cases of progressive vaccinia; it might be useful also in the treatment of ocular vaccinia resulting from inadvertent implantation. However, vaccinia immunoglobulin is contraindicated for the treatment of vaccinial keratitis. Vaccinia immunoglobulin is recommended for severe generalized vaccinia if the individual is extremely ill or has a serious underlying disease. Vaccinia immunoglobulin provides no benefit in the treatment of post-vaccinial encephalitis and has no role in the treatment of smallpox. The Centers for Disease Control and Prevention (CDC) (2001) states that current supplies of vaccinia immunoglobulin are limited, and its use should be reserved for treatment of vaccine complications with serious clinical manifestations. According to the CDC (2001), vaccinia immunoglobulin should be administered as early as possible after the onset of symptoms. Doses can be repeated, usually at intervals of 2-3 days, until recovery begins (e.g., no new lesions appear). The CDC is currently the only source of vaccinia immunoglobulin for civilians.
Rabies Immue Globulin
Rabies immune globulin is indicated for treatment of rabies exposure where the animal has escaped or is known to be rabid at the time of direct exposure or attack. Treatment of rabies exposure is comprised of a series of rabies vaccine (human diploid cell vaccine, HDCV) and a single rabies immune globulin injection (Rabies Immune Globulin, RIG). For persons not previously vaccinated with HDCV, the usual frequency is a single intramuscular injection of RIG and a series of HDCV consisting of 1-milliliter intramuscular injection in the deltoid area on days 0, 3, 7, 14, and 28. For persons previously vaccinated with HDCV, two HDCV intramuscular injections are given on days 0 and 3. The literature indicates rabies immune globulin should not be administered to previously vaccinated individuals.
Tetanus Immune Globulin
Intramuscular injection of tetanus immune gamma globulin are indicated for prevention of tetanus in immunized or non-immunized persons for neglected or tetanus-prone wounds (contaminated, necrotizing, or puncture wounds). Post-exposure prophylaxis with tetanus toxoid is recommended under accepted guidelines for wounded persons who have not completed the 3-dose primary vaccination series, and those who have completed vaccination more than 10 years ago. In addition, accepted guidelines state incompletely vaccinated persons with serious or contaminated wounds should receive human tetanus immune globulin. The usual dose is a single intramuscular injection repeated at 4-week intervals, if necessary.
Rubeola (Measles) Immune Globulin
Intramuscular injection of measles (rubeola) immune globulin is indicated for unvaccinated individuals exposed to the disease. Accepted guidelines recommend that the immune globulin should be administered within 6 days of exposure.
Immune Globulin for Rubella (German Measles)
The use of immune globulin for pregnant women with acute infection is controversial. There are no data to suggest that immune globulin will have any beneficial effect on the fetal response to disease. Thus, the Centers for Disease Control and Prevention recommends limiting the use of immune globulin to women with known rubella exposure who decline pregnancy termination. The usual dose of immune globulin is a single intramuscular injection.
CPT Codes / ICD-9 Codes / HCPCS Codes
Hepatitis A Immune Globulin:
CPT codes covered if selection criteria are met [no specific code]:
90399
HCPCS codes covered if selection criteria are met:
J1460
Injection, gamma globulin, intramuscular, 1 cc
J1470
Injection, gamma globulin, intramuscular, 2 cc
J1480
Injection, gamma globulin, intramuscular, 3 cc
J1490
Injection, gamma globulin, intramuscular, 4 cc
J1500
Injection, gamma globulin, intramuscular, 5 cc
J1510
Injection, gamma globulin, intramuscular, 6 cc
J1520
Injection, gamma globulin, intramuscular, 7 cc
J1530
Injection, gamma globulin, intramuscular, 8 cc
J1540
Injection, gamma globulin, intramuscular, 9 cc
J1550
Injection, gamma globulin, intramuscular, 10 cc
J1560
Injection, gamma globulin, intramuscular, over 10 cc
ICD-9 codes covered if selection criteria are met:
V01.79
Contact with or exposure to other viral diseases
V15.85
Exposure to potentially hazardous body fluids
ICD-9 codes not covered for indications listed in the CPB:
070.0
Viral hepatitis A with hepatic coma
070.1
Viral hepatitis A without mention of hepatic coma
Other ICD-9 codes related to the CPB:
V05.3
Need for prophylactic vaccination and inoculation against viral hepatitis
V07.2
Prophylactic immunotherapy
V70.5
Health examination of defined subpopulations
Hepatitis B Immune Globulin:
CPT codes covered if selection criteria are met:
90371
HCPCS codes covered if selection criteria are met:
J1571
Injection, hepatitis B immune globulin (Hepagam B), intramuscular, 0.5 ml
J1573
Injection, hepatitis B immune globulin (Hepagam B), intravenous, 0.5 ml
ICD-9 codes covered if selection criteria are met:
V01.79
Contact with or exposure to other viral diseases
V15.85
Exposure to potentially hazardous body fluids
V42.7
Liver replaced by transplant
ICD-9 codes not covered for indications listed in the CPB:
070.20 - 070.23
Viral hepatitis B with hepatic coma
070.30 - 070.33
Viral hepatitis B without mention of hepatic coma
Other ICD-9 codes related to the CPB:
V05.3
Need for prophylactic vaccination and inoculation against viral hepatitis
V07.2
Prophylactic immunotherapy
Cytomegalovirus Immune Globulin:
CPT codes covered if selection criteria are met:
90291
HCPCS codes covered if selection criteria are met:
J0850
Injection, cytomegalovirus immune globulin intravenous (human), per vial
ICD-9 codes covered if selection criteria are met:
078.5
Cytomegaloviral disease
484.1
Pneumonia in cytomegalic inclusion disease
771.1
Congenital cytomegalovirus infection
996.80 - 996.89
Complications of transplanted organs
V01.79
Contact with or exposure to other viral diseases
V42.0 - V42.9
Organ or tissue replaced by transplant
ICD-9 codes not covered for indications listed in the CPB:
273.3
Macroglobulinemia
279.01
Selective IgA immunodeficiency
Rho-D immune Globulin:
CPT codes covered if selection criteria are met:
90384
90385
90386
Other CPT codes related to the CPB:
59000
59012
59015
59072
59074
59076
59412
59812 - 59857
HCPCS codes covered if selection criteria are met:
J2788
Injection, Rho D immune globulin, human, minidose, 50 mcg
J2790
Injection, Rho D immune globulin, human, full dose, 300 mcg
J2791
Injection, Rho D immune globulin, human (Rhophylac), intramuscular or intravenous, 10 IU
J2792
Injection, Rho D immune globulin, intravenous, human, solvent detergent, 100 IU
ICD-9 codes covered if selection criteria are met:
287.31
Immune thrombocytopenia purpura
632
Missed abortion
633.00 - 633.91
Ectopic pregnancy
634.00 - 634.92
Spontaneous abortion
641.10 - 641.13
Hemorrhage from placenta previa
641.20 - 641.23
Premature separation of placenta
656.40 - 656.43
Intrauterine death
Other ICD-9 codes related to the CPB:
656.10 - 656.13
Rhesus isoimmunization complicating pregnancy, childbirth, and the puerperium
656.20 - 656.23
Isoimmunization from other and unspecified blood-group incompatibility, complicating pregnancy, childbirth, and the puerperium
V07.2
Prophylactic immunotherapy
Rabies Immune Globulin:
CPT codes covered if selection criteria are met:
90375
90376
ICD-9 codes covered if selection criteria are met:
V01.5
Contact with or exposure to rabies
Other ICD-9 codes related to the CPB:
071
Rabies
V04.5
Need for prophylactic vaccination against rabies
Varicella Zoster Immune Globulin:
CPT codes covered if selection criteria are met:
90396
HCPCS codes covered if selection criteria are met:
J1460
Injection, gamma globulin, intramuscular, 1 cc
J1470
Injection, gamma globulin, intramuscular, 2 cc
J1480
Injection, gamma globulin, intramuscular, 3 cc
J1490
Injection, gamma globulin, intramuscular, 4 cc
J1500
Injection, gamma globulin, intramuscular, 5 cc
J1510
Injection, gamma globulin, intramuscular, 6 cc
J1520
Injection, gamma globulin, intramuscular, 7 cc
J1530
Injection, gamma globulin, intramuscular, 8 cc
J1540
Injection, gamma globulin, intramuscular, 9 cc
J1550
Injection, gamma globulin, intramuscular, 10 cc
J1560
Injection, gamma globulin, intramuscular, over 10 cc
ICD-9 codes covered if selection criteria are met:
765.21 - 765.24
Weeks of gestation, less than 24 weeks of gestation to 27-28 completed weeks of gestation
V01.71
Contact with or exposure to varicella
Other ICD-9 codes related to the CPB:
052.0 - 052.9
Chickenpox
279.00 - 279.9
Disorders of the immune mechanism
647.60 - 647.64
Other viral diseases in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium
765.00 - 765.19
Extreme immaturity and other preterm infants
771.2
Other congenital infections
771.89
Other infections specific to the perinatal period
V05.4
Need for prophylactic vaccination and inoculation against varicella
V07.2
Prophylactic immunotherapy
Tetanus Immune Globulin:
CPT codes covered if selection criteria are met:
90389
HCPCS codes covered if selection criteria are met:
J1670
Injection tetanus immune globulin, human, up to 250 units
ICD-9 codes covered if selection criteria are met:
728.86
Necrotizing fasciitis
870.0 - 897.7
Open wound [complicated only] [contaminated, necrotizing, puncture]
Need for prophylactic vaccination and inoculation against bacterial disease, tetanus toxoid alone
V06.1
Need for prophylactic vaccination and inoculation against combinations of diseases, diphtheria-tetanus-pertussis, combined [DTP] [DTaP]
V07.2
Prophylactic immunotherapy
Rubeola (Measles) Immune Globulin:
CPT codes covered if selection criteria are met [no specific code]:
90399
HCPCS codes covered if selection criteria are met:
J1460
Injection, gamma globulin, intramuscular, 1 cc
J1470
Injection, gamma globulin, intramuscular, 2 cc
J1480
Injection, gamma globulin, intramuscular, 3 cc
J1490
Injection, gamma globulin, intramuscular, 4 cc
J1500
Injection, gamma globulin, intramuscular, 5 cc
J1510
Injection, gamma globulin, intramuscular, 6 cc
J1520
Injection, gamma globulin, intramuscular, 7 cc
J1530
Injection, gamma globulin, intramuscular, 8 cc
J1540
Injection, gamma globulin, intramuscular, 9 cc
J1550
Injection, gamma globulin, intramuscular, 10 cc
J1560
Injection, gamma globulin, intramuscular, over 10 cc
ICD-9 codes covered if selection criteria are met:
V01.79
Contact with or exposure to other viral diseases
Other ICD-9 codes related to the CPB:
055.0 - 055.9
Measles
V07.2
Prophylactic immunotherapy
Immune Globulin (IVIG) for German Measles (Rubella):
CPT codes covered if selection criteria are met [no specific code]:
90399
HCPCS codes covered if selection crieria are met:
J1460
Injection, gamma globulin, intramuscular, 1 cc
J1470
Injection, gamma globulin, intramuscular, 2 cc
J1480
Injection, gamma globulin, intramuscular, 3 cc
J1490
Injection, gamma globulin, intramuscular, 4 cc
J1500
Injection, gamma globulin, intramuscular, 5 cc
J1510
Injection, gamma globulin, intramuscular, 6 cc
J1520
Injection, gamma globulin, intramuscular, 7 cc
J1530
Injection, gamma globulin, intramuscular, 8 cc
J1540
Injection, gamma globulin, intramuscular, 9 cc
J1550
Injection, gamma globulin, intramuscular, 10 cc
J1560
Injection, gamma globulin, intramuscular, over 10 cc
ICD-9 codes covered if selection criteria are met:
647.50 - 647.54
Rubella, complicating pregnancy, childbirth, and the puerperium
V01.4
Contact with or exposure to rubella
Other ICD-9 codes related to the CPB:
056.0 - 056.9
Rubella
V07.2
Prophylactic immunotherapy
Vaccinia (Smallpox) Immune Globulin:
CPT codes covered if selection criteria are met:
90393
ICD-9 codes covered if selection criteria are met:
999.0
Generalized vaccinia
V01.3
Contact with or exposure to smallpox
Other ICD-9 codes related to the CPB:
050.0 - 050.9
Smallpox
323.51
Encephalitis following immunization procedures
V04.1
Need for prophylactic vaccination and inoculation against smallpox
V07.2
Prophylactic immunotherapy
ICD-9 codes contraindicated for this CPB:
370.0 - 370.9
Keratitis
The above policy is based on the following references:
American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG). Guidelines for Perinatal Care. 4th ed. Elk Grove Village, IL: AAP; August 1997.
American Academy of Pediatrics (AAP). 1997 Red Book. Report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, IL: AAP; 1997.
Centers for Disease Control and Prevention. Rubella prevention. Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Recomm Rep.1990;39(RR-15):1-18.
Centers for Disease Control and Prevention. Hepatitis B: A comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination. Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Recomm Rep. 1991;40(RR-13):1-25.
Centers for Disease Control and Prevention. Prevention of varicella. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1996;45(RR-11):1-36.
Centers for Diseae Control. Recommendations of the Immunization Practices Advisory Committee. Varicella-zoster immune globulin for the prevention of chickenpox. Ann Intern Med. 1984;100(6):859-865.
Centers for Disease Control and Prevention. Measles, mumps, and rubella -- vaccine use and strategies for the elimination of measles, rubella, and congenital rubella syndrome and control of mumps: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1998;47(RR-8):1-57.
Centers for Disease Control. Rabies prevention -- United States, 1984. MMWR Morb Mortal Wkly Rep. 1984;33(28):393-402, 407-408.
Centers for Disease Control and Prevention. Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1996;45(RR-15):1-30.
Centers for Disease Control and Prevention. Diptheria, tetanus, and pertussis: Recommendations for vaccine use and other preventive measures. Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Recomm Rep. 1991;40(RR-10):1-28.
Falagas ME. Cytomegalovirus immune globulin (CMVIG) prophylaxis is associated with increased survival after orthotopic liver transplantation. The Boston Center for Liver Transplantation CMVIG Study Group. Clin Transplant. 1997;11(5 Pt 1):432-437.
Gajarski RJ. Outcomes among pediatric heart transplant recipients. Tex Heart Inst J. 1997;24(2):97-104.
Dickinson BI, Gora-Harper ML, McCraney SA, Gosland M. Studies evaluating high-dose acyclovir, intravenous immune globulin, and cytomegalovirus hyperimmunoglobulin for prophylaxis against cytomegalovirus in kidney transplant recipients. Ann Pharmacother. 1996;30(12):1452-1464.
Centers for Diseae Control and Prevention. Vaccinia (smallpox) vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1991;40(RR-14):1-10.
Health Technology Board for Scotland (HTBS). The use of anti-D prophylaxis for rhesus negative women in pregnancy. Understanding HTBS Advice. Glasgow, Scotland; HTBS; 2002.
Centers for Disease Control and Prevention (CDC). Use of smallpox (vaccinia) vaccine, June 2002. Supplemental recommendation of the ACIP. Atlanta, GA: CDC; June 2002. Available at: http://www.cdc.gov/nip/smallpox/supp_recs.htm. Accessed June 24, 2002.
Kamoltham T, Singhsa J, Promsaranee U, et al. Elimination of human rabies in a canine endemic province in Thailand: Five-year programme. Bull World Health Organ. 2003;81(5):375-381.
Hong Z, Gao RN, Zou S. Hepatitis B immune globulin for prevention of posttransplantation hepatitis B (Protocol for Cochrane Review). Cochrane Database Syst Rev. 2004;(4):CD004995.
Lee C, Gong Y, Brok J, et al. Hepatitis B prophylaxis for newborns of hepatitis B surface antigen-positive mothers. Cochrane Database Syst Rev. 2006;(2):CD004790.
Swingler G. Chickenpox. In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; March 2007.
Chilcott J, Lloyd Jones M, Wight J, et al. A review of the clinical effectiveness and cost-effectiveness of routine anti-D prophylaxis for pregnant women who are Rhesus-negative. Health Technol Assess. 2003;7(4):1-72.
Powell JJ, Apiratpracha W, Partovi N, et al. Subcutaneous administration of hepatitis B immune globulin in combination with lamivudine following orthotopic liver transplantation: effective prophylaxis against recurrence. Clin Transplant. 2006;20(4):524-525.
Karademir S, Astarcioglu H, Akarsu M, et al. Prophylactic use of low-dose, on-demand, intramuscular hepatitis B immunoglobulin and lamivudine after liver transplantation. Transplant Proc. 2006;38(2):579-583.
Karasu Z, Ozacar T, Akyildiz M, et al. Low-dose hepatitis B immune globulin and higher-dose lamivudine combination to prevent hepatitis B virus recurrence after liver transplantation. Antivir Ther. 2004;9(6):921-927.
Buti M, Mas A, Prieto M, et al. A randomized study comparing lamivudine monotherapy after a short course of hepatitis B immune globulin (HBIg) and lamivudine with long-term lamivudine plus HBIg in the prevention of hepatitis B virus recurrence after liver transplantation. J Hepatol. 2003;38(6):811-817.
Park SJ, Paik SW, Choi MS, et al. Is lamivudine with 1-week HBlg as effective as long-term high-dose HBlg in HBV prophylaxis after liver transplantation? Transplant Proc. 2002;34(4):1252-1254.
Lee KW, Lee SK, Joh JW, et al. Comparison of the efficacy in prevention of hepatitis B virus recurrence after liver transplantation between HBIG and lamivudine. Transplant Proc. 2001;33(7-8):3643-3644.
Naoumov NV, Lopes AR, Burra P, et al. Randomized trial of lamivudine versus hepatitis B immunoglobulin for long-term prophylaxis of hepatitis B recurrence after liver transplantation. J Hepatol. 2001;34(6):888-894.
Tchervenkov JI, Tector AJ, Barkun JS, et al. Recurrence-free long-term survival after liver transplantation for hepatitis B using interferon-alpha pretransplant and hepatitis B immune globulin posttransplant. Ann Surg. 1997;226(3):356-368.
Burbach GJ, Bienzle U, Neuhaus R, et al. Intravenous or intramuscular anti-HBs immunoglobulin for the prevention of hepatitis B reinfection after orthotopic liver transplantation. Transplantation. 1997;63(3):478-480.
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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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