Immunization is a technique used to induce immune resistance to a specific disease in humans by exposing the individual to an antigen in order to raise antibodies to that antigen. This process increases an individual's reaction to an antigen and therefore improves the ability to resist or overcome infection. This document addresses the use of childhood and adult immunizations.

Medically Necessary:

For Childhood Immunizations:
The most recent recommendations of the American Academy of Family Physicians (AAFP), or the American Academy of Pediatrics (AAP), or the affirmative recommendations of the Advisory Committee on Immunization Practices (ACIP) for the Centers for Disease Control and Prevention (CDC) for childhood immunizations are considered medically necessary.

For Adult Immunizations:
The most recent recommendations of the American Academy of Family Physicians (AAFP) or affirmative recommendations of the Advisory Committee on Immunization Practices (ACIP) for the Centers for Disease Control and Prevention (CDC) for adult immunizations are considered medically necessary.

Note:
Permissive recommendations of the Advisory Committee on Immunization Practices (ACIP) for the Centers for Disease Control and Prevention (CDC) for childhood and adult immunizations are reviewed on an individual basis to determine medical necessity and will be listed in the position statement of this document when determined to be not medically necessary.

Generally, immunizations are among the safest and most effective medicines. The overwhelming majority of medical experts in the United States and abroad believe that the benefits of complete immunization far outweigh the risks. The health experts in many countries are in full accord with the concept that everyone who is healthy should be immunized as recommended.

ACIP (Advisory Committee on Immunization Practices), a United States federal advisory committee, provides guidance to the Secretary and the Assistant Secretary for Health and Human Services, and the Director, Centers for Disease Control and Prevention (CDC), regarding vaccines and related agents for control of vaccine-preventable diseases within the United States. As a result of the Omnibus Budget Reconciliation Act of 1993, ACIP assumed the role of developing a list of vaccines for administration to children eligible to receive vaccines through the Vaccines for Children (VFC) Program, along with schedules regarding correct dosages, dosing intervals and contraindications applicable to pediatric vaccines. VFC resolutions passed by ACIP form the basis for VFC program policies on vaccine availability and usage.

Following an ACIP vaccination recommendation (vote), a full recommendation (ACIP statement) will be posted as a provisional recommendation on the ACIP website within three weeks. Provisional recommendations are under review by the Director of CDC and the Department of Health and Human Services (HHS). Provisional recommendations will become official when published in CDC's Morbidity and Mortality Weekly Report (MMWR). Publication occurs within 6 to 8 months of an ACIP vote. Provisional recommendation provides interim information for healthcare personnel on ACIP recommendations most recently voted upon that have yet to be officially approved by HHS and the CDC.

Full recommendations developed by ACIP may be either affirmative or permissive recommendations. Affirmative recommendations are characterized as routine, catch-up and risk based. Routine vaccinations are most commonly implemented for a specific age group; catch-up vaccinations are usually for defined periods of time and cohorts; and risk-based recommendations are typically those for a high risk population. A permissive recommendation is issued to reflect situations where vaccination may be effective, but ACIP is not recommending routine use. 

Immunization is the process of inducing or providing immunity artificially by administering an immunobiologic. Immunization can be active or passive. Active immunization is the production of antibody or other immune responses through the administration of a vaccine or toxoid. Passive immunization means the provision of temporary immunity by the administration of preformed antibodies. Recommendations for vaccinating infants, children, and adults are based on characteristics of immunobiologics, scientific knowledge about the principles of active and passive immunization and the epidemiology of diseases, and judgments by public health officials and specialists in clinical and preventive medicine. 

Immunization programs help build defenses against disease. Immunizations should be started early and carried out on a regular and routine basis. Immunizations are important, for example, with the childhood diseases (measles, mumps, rubella, diphtheria, tetanus, pertussis, haemophilus influenzae type b, and polio) that are preventable by immunization.

Childhood immunizations consist of a series of intramuscular, subcutaneous injections or oral dosing of inactivated bacteria, toxoids, live attenuated viruses, or inactive viral antigens against several diseases: diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, haemophilus influenzae type b, human papilloma virus, hepatitis A, hepatitis B, influenza, varicella, pneumococcus and rotavirus. Many of the immunizations are given as combined vaccines during routine well-child checks in the first two years of life. Immunizations against diseases for which risk factors are related to adolescent issues are recommended at ages prior to when exposure most frequently occurs. These include meningitis, hepatitis B and human papillomavirus. 

Most of the adult immunizations are administered in primary series (in previously unimmunized persons), booster doses, and periodic doses. Agents include toxoids (diphtheria and tetanus), live virus vaccines (measles, mumps, and rubella), influenza, inactive viral particles (hepatitis B), highly purified virus-like particles (HPV) and inactivated bacterial polysaccharide vaccine (pneumococcal).

Recommended Immunization Schedules are grouped by types of vaccine and the recipient's age. Certain vaccinations are present on both childhood and adult schedules, while others are limited to a specific schedule. Examples of ACIP recommendations which are limited to specific ages include:

• Human papillomavirus (HPV) vaccination (with either quadrivalent [HPV4] vaccine or bivalent vaccine [HPV2]) is recommended for those aged 9 through 26.
• Live attenuated influenza vaccine (FluMist^®) is recommended for healthy non pregnant persons aged 2 years through 49 years.
• Zoster vaccine is recommended as a single dose for adults aged 60 years and older.

Like other medicines, vaccines can cause side effects but these are usually very mild and of short duration. Side effects may include a slight fever, a sore arm, or a mild rash.

Antibody: A type of protein produced by the immune system in response to foreign substances that may be a threat to the body -- such as chemicals, virus particles, spores, or bacterial toxins. These foreign substances are called antigens. Each type of antibody is unique and defends the body against one specific type of antigen.

Antigen: Any substance that, when introduced into the body, evokes an immune response and stimulates the production of antibodies.

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Medically Necessary:
The following specific vaccine codes do not have age as part of the code descriptor; however appropriate ages are listed below based on ACIP guideline recommendations:

Government Agency, Medical Society, and Other Authoritative Publications: 

1. American Academy of Family Physicians. Immunization Schedules, 2011. Available at: http://www.aafp.org/online/en/home/clinical/immunizationres.html. Accessed on October 4, 2011.
2. American Academy of Pediatrics 2011 Immunization Schedules. Available at: http://www.aap.org/immunization/IZSchedule.html. Accessed on October 4, 2011.
3. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). FDA approval of expanded age indication for a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. MMWR 2011; 60 (37); 1279-1280. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6037a3.htm?s_cid=mm6037a3_e&source=govdelivery. Accessed on October 5, 2011.
4. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). FDA licensure of bivalent human papillomavirus vaccine (HPV2, Cervarix) for use in females and updated HPV vaccination recommendations from the Advisory Committee on Immunization Practices (ACIP). MMWR 2010; 59(20); 626-629. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5920a4.htm?s_cid=mm5920a4_e. Accessed on October 4, 2011.
5. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). Licensure of a meningococcal conjugate vaccine for children aged 2 through 10 years and updated booster dose guidance for adolescents and other persons at increased risk for meningococcal disease from the Advisory Committee on Immunization Practices (ACIP). MMWR 2011; 60(30); 1018-1019. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6030a3.htm?s_cid=mm6030a3_e&source=govdelivery. Accessed on October 4, 2011.
6. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). Prevention and control of influenza with vaccines. MMWR 2011; 60(33); 1128-1132. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6033a3.htm?s_cid=mm6033a3_w. Accessed on October 4, 2011.
7. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). Prevention of pneumococcal disease among infants and children - use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine - recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2010; 59(RR-11); 1-18. Available at: http://www.cdc.gov/mmwr/PDF/rr/rr5911.pdf. Accessed on October 4, 2011.
8. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). Recommendation of the Advisory Committee on Immunization Practices (ACIP) for use of quadrivalent meningococcal conjugate vaccine (MenACWY-D) among children aged 9 through 23 months at increased risk for invasive meningococcal disease. MMWR 2011; 60(40); 1391-1392. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6040a4.htm?s_cid=mm6040a4_e&source=govdelivery. Accessed on October 14, 2011.
9. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). Recommendations on the use of quadrivalent human papillomavirus vaccine in males — Advisory Committee on Immunization Practices (ACIP). MMWR 2011; 60(50); 1705-1708. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6050a3.htm?s_cid=mm6050a3_e. Accessed on December 28, 2011.
10. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). Update on herpes zoster vaccine: licensure for persons aged 50 through 59 years. MMWR 2011; 60(44); 1528. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6044a5.htm?s_cid=mm6044a5_e%0d%0a. Accessed on December 28, 2011.
11. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR 2010: 59(34); 1102-1106. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5934a3.htm. Accessed on October 4, 2011.
12. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). Updated recommendations for use of meningococcal conjugate vaccines. MMWR 2011; 60(03); 72-76. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6003a3.htm?s_cid=mm6003a3_e. Accessed on October 4, 2011.
13. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine. MMWR 2011; 60(01); 13-15. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6001a4.htm?s_cid=mm6001a4_e&source=govdelivery. Accessed on October 4, 2011.
14. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) in pregnant women and persons who have or anticipate having close contact with an infant aged <12 months. MMWR 2011; 60(41); 1424-1426. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6041a4.htm?s_cid=mm6041a4_e&source=govdelivery. Accessed on October 24, 2011.
15. Centers for Disease Control and Prevention. Recommended adult immunization schedule --- United States, 2011. MMWR 2011; 60(4) 1-4. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6004a10.htm?s_cid=mm6004a10_e&source=govdelivery. Accessed on October 4, 2011.
16. Centers for Disease Control and Prevention. Recommended immunization schedules for persons aged 0 through 18 years --- United States, 2011. MMWR 2011; 60(5); 1-4. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6005a6.htm?s_cid=mm6005a6_e&source=govdelivery. Accessed on October 4, 2011.

1. Centers for Disease Control and Prevention. Recommendations and Guidelines: Advisory Committee on Immunization Practices (ACIP). Available at: http://www.cdc.gov/vaccines/recs/acip/default.htm. Accessed on October 4, 2011.

Cervarix^®
Diphtheria
Gardasil^®
Herpes Zoster
HPV
Human Papillomavirus
Immunizations
Influenza
Inoculations
Measles
Meningococcal
MMR
Mumps
Pertussis
Pneumococcal
Poliovirus
Rotarix^®
RotaTeq^®
Rotavirus
Rubella
Td/Tdap
Tdap
Tetanus
Vaccines
Varicella