Medicare coverage policy for Flu and pneumoccccal vaccine

Coverage Criteria

B1. What are Medicare’s coverage criteria for flu vaccinations?

Effective for services performed on or after May 1, 1993, Medicare will pay for flu virus vaccines and their administration. Generally, only one flu virus vaccination is medically necessary per year. Medicare beneficiaries may receive the vaccine once each flu season without a physician's order and without the supervision of a physician. However, state laws regarding who can administer vaccines still apply. The Medicare Part B deductible and coinsurance do not apply. Additional vaccination may be covered if medically necessary.

B2. What are Medicare’s coverage criteria for Pneumococcal Polysaccharide Vaccine (PPV) vaccinations?

Effective for services performed on or after July 1, 1981, Medicare began paying for PPV and its administration. Typically, this vaccine is administered once in a lifetime except for persons at highest risk.
Effective for claims with dates of service on or after July 1, 2000, Medicare no longer requires the PPV to be ordered by a doctor of medicine or osteopathy. However, state laws regarding who can administer vaccines still apply. Therefore, the beneficiary may receive the vaccine upon request without physician’s supervision. However, state laws regarding who can administer vaccines still apply.

Medicare will only cover an initial vaccine administered to persons at high risk of pneumococcal disease. Considered at high risk are persons 65 years of age or older and immunocompetent adults who are at increased risk of pneumococcal disease or its complications because of chronic illness.
Provided that at least five years have passed since receipt of a previous dose of PPV vaccine, revaccination may be administered only to persons at highest risk of serious pneumococcal infection and those likely to have a rapid decline in pneumococcal antibody levels. This group includes persons with functional or anatomic asplenia (e.g., sickle cell disease, splenectomy), HIV infection, leukemia, lymphoma, Hodgkin's disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome, or other conditions associated with immunosuppression such as organ or bone marrow transplantation, and those receiving immunosuppressive chemotherapy. Routine revaccination of people age 65 or older is not appropriate, unless determined medically necessary by a physician, unless initial vaccination was given before age 65, and 5 years has passed.

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