UPMC Health Plan

UPMC Health Plan POLICY AND PROCEDURE MANUAL POLICY NUMBER: PAY.004 REVISION DATE: 04/09 ANNUAL APPROVAL DATE: 06/09 PAGE NUMBER: 1 of 4 SUBJECT: INDEX TITLE: ORIGINAL DATE: Rotavirus Vaccine Medical Management March 2006 This policy applies to the following lines of business: (Check those that apply.) Commercial: HMO ( ) Fully Insured ( ) Medicare Select ( ) DPW-MA: Health Choices ( ) CMS-MA: HMO (X ) PPO (X PID-CHIP: Free ( ) POS ( ) Self-funded/ASO ( ) Medicare Supplement ( ) Voluntary ( ) Specialty Needs Plan (X) Sub ( ) PPO ( ) HSA ( ) OOA/DOC ( ) All (X ) All ( X ) PFFS (X ) All ( ) All ( X ) Part D ( ) I. POLICY It is the policy of UPMC Health Plan to recognize the value of preventive medicine as appropriate and consistent with good medical practice and will provide coverage of the vaccine for prevention of Pediatric Rotovirus Gastroenteritis when the services are medically necessary as described in this policy and according to the member’s individual benefit plan. II. DEFINITIONS Rotovirus: A genus of viruses that causes acute infantile gastroenteritis and diarrhea. 111. PURPOSE The purpose of this policy is to identify the vaccines for Rotovirus Gastroenteritis currently approved to describe the indications for this vaccine. IV. SCOPE This policy applies to various UPMC Health Plan Departments as indicated by the Benefit and Reimbursement Committees. These include, but are not limited to, Medical Management, Benefit Configuration and Claims Departments. Proprietary and Confidential Information of UPMC Health Plan POLICY NUMBER: PAY.004 REVISION DATE: 04/09 ANNUAL APPROVAL DATE: 06/09 PAGE NUMBER: 2 of 4 V. PROCEDURE A. Medical Description Rotavirus gastroenteritis is a leading cause of severe dehydrating diarrhea in infants and young children and accounts for 2 million hospital visits and 500,000 pediatric deaths each year worldwide. It is caused by a genus of viruses. RotaTeq® and RotarixI® are oral, liquid vaccines, which are part of the routine childhood immunization program. They provide protection against five serotypes of rotavirus, including serotypes G1, G2, G3, G4 and P1. B. Indications The rotavirus vaccine is covered under the routine Preventive Immunization guidelines for Children. 1. RotaTeq® immunization is achieved by administering 3 doses between 6-32 weeks in children. Recommendation: Immunize at 2, 4 and 6 months of age. 2. Rotarix® immunization is achieved by administering 2 doses between 6-24 weeks in children. Recommendation: Immunize at 2 and 4 months of age. C. Limitations Rotavirus vaccine is not recommended for infants less than six (6) weeks of age or older than 32 weeks (8 months) of age. D. N/A Variations E. References 1. Parashar UD, Holman RC, Clarke MJ, et al. Hospitalizations associated with rotavirus diarrhea in the United States, 1993 through 1995: Surveillance based on the new ICD9-CM rotavirus-specific diagnostic code. J Infect Dis. 1998; 177:13-17. 2. Murphy TV, Gargiullo PM, Massoudi MS, et al. Intussusception among infants given an oral rotavirus vaccine. N Engl J Med. 2001; 344:564-572. 3. Centers for Disease Control and Prevention (CDC). General recommendations on immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP). MMWR Morbid Mortal Wkly Rep. 2002; 51(RR-2):1-35. 4. Edwards K. New vaccines on the horizon. Program and abstracts of the American Academy of Pediatrics National Conference & Exhibition 2004; October 9 13,2004, San Francisco, CA Session P407 5. Merck & Co., Inc. Rotateq (rotavirus vaccine, live, oral, pentavalent). Prescribing Information 9714300. Whitehouse Station, JR: February, 2006. http://www.fda.gov/cber/products/rotamer020308.htm. Proprietary and Confidential Information of UPMC Health Plan POLICY NUMBER: PAY.004 REVISION DATE: 04/09 ANNUAL APPROVAL DATE: 06/09 PAGE NUMBER: 3 of 4 6. Merck & Co., Inc. FDA approves Merck’s Rotateq, the only vaccine in the U.S. to prevent rotavirus gastroenteritis, a leading cause of severe infant diarrhea. Press Release. Whitehouse Station, NJ: Merck & Co; February 3, 2006. http://www.mercvk.com/newsroom/press.releases/product/2006_0203.html. 7. RotaTeq Rotavirus Vaccine.About.com: Pediatrics RotaTec Facts; http://pediatrics.about.com/od/immunizations/p/06.rotateq.htm 8. Center for Disease Control: Advisory Committee on Immunizations Practices, Vaccines For Children Program, Vaccines to Prevent Rotavirus Gastroenteritis, Resolution No. 6/08-1. http://www.cdc.gov/vaccines/programs/vfc/downloads/resolutions/0608rotavirus.pdf 9. FDA News: FDA Approves New Vaccine To Prevent Gastroenteritis Caused by Rotavirus, April 3, 2008. http://www.fda.gov/bbs/topics/NEWS/2008/NEW01814.html 10. CDC Pediatric Recommended Immunization Schedule for Persons Aged 0 Through 6 Years, United States 2009. http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2009/09_06yrs_schedule_pr.pdf 11. UPMC Health Plan Pediatric Preventative Guidelines 2009. http://www.upmchealthplan.com/online/pdf/2009_Pediatric_Preventive_Guideline.pdf Proprietary and Confidential Information of UPMC Health Plan POLICY NUMBER: PAY.004 REVISION DATE: 04/09 ANNUAL APPROVAL DATE: 06/09 PAGE NUMBER: 4 of 4 Disclaimer: UPMC Health Plan medical payment and prior authorization policies do not constitute medical advice and are not intended to govern or otherwise influence the practice of medicine. The policies constitute only the reimbursement and coverage guidelines of UPMC Health Plan and its affiliated managed care entities. Coverage for services varies for individual members in accordance with the terms and conditions of applicable Certificates of Coverage, Summary Plan Descriptions, or contracts with governing regulatory agencies. UPMC Health Plan reserves the right to review and update the medical payment and prior authorization guidelines in its sole discretion. Notice of such changes, if necessary, shall be provided in accordance with the terms and conditions of provider agreements and any applicable laws or regulations. These policies are the proprietary information of UPMC Health Plan. Any sale, copying, or dissemination of said policies is prohibited. Proprietary and Confidential Information of UPMC Health Plan