Policy:

(Note: For Medicare Advantage, please refer to the Medicare Coverage Section below for coverage guidance.)

1. Intranasal influenza virus live vaccine (FluMist Quadrivalent) is considered medically necessary in the 2020-2021 flu season in patients aged 2 through 49 years of age for the active immunization and prevention of influenza caused by influenza A subtype viruses and type B viruses contained in the vaccine.

[ INFORMATIONAL NOTE: Per the Center for Disease Control Influenza Surveillance data, the typical flu season begins in October and ends in March. As such, the FluMist Quadrivalent vaccination will be available from September 2020 until March 2021.]

Medicare Coverage
Per MLN SE19022, issued September 9, 2019, FluMist Quadrivalent (CPT code 90672) is covered for the August 1, 2019 through July 31, 2020 season. For additional information and eligibility, refer to MLN Matters Number: SE19022: 2019-2020 Influenza (Flu) Resources for Health Care Professionals. Article Release Date: September 9, 2019. Available at MLN general search page: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/Index.html

FluMist Quadrivalent (CPT code 90672) is also covered for the 2020-2021 influenza season. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing

Medicaid Coverage
For Horizon NJ Health members, please follow this link for the corresponding HNJH drug policy https://services3.horizon-bcbsnj.com/ddn/NJhealthWeb.nsf

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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Intranasal Influenza Virus Vaccine (FluMist)
FluMist (Intranasal Influenza Virus Vaccine)
Intranasal Influenza Virus Vaccine (FluMist Quadrivalent)
FluMist Quadrivalent (Intranasal Influenza Virus Vaccine)

References:

1. U.S. food and Drug Administration. FDA News: First Nasal Mist Flu Vaccine Approved. June 17, 2003. http://www.fda.gov/bbs/topics/NEWS/2003/NEW00913.html

33. Centers for Disease Control and Prevention. Immunization schedules. https://www.cdc.gov/vaccines/schedules/index.html. Accessed July 18, 2019.

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

90660
90672