CurrentCapital BluecrossPolicy MP 2.381

DENGVAXIA

Defines medical necessity criteria and coding for Dengvaxia (dengue vaccine) for eligible members of Capital Blue Cross programs, including age, prior infection confirmation, and residence in endemic areas.

Policy Summary

PayerCapital Bluecross

PolicyDENGVAXIA

Policy CodePolicy MP 2.381

Change TypeNo material change

Effective DateSep 1, 2025

Next Review Date

Key ActionObtain and document laboratory confirmation of prior dengue infection and evidence of residence in an endemic area before vaccination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9-16age range eligible for vaccination

Lab-confirmedrequired evidence of prior dengue infection

Endemic areageographic requirement for eligibility

90587covered procedure code (vaccine administration)

Dengvaxiaproduct referenced

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Coverage and Medical Necessity Criteria

Medical necessity criteria

Covered when ALL of the following are met:

Eligibility for Dengvaxia: Member is 9 through 16 years of age

Age requirement per FDA indication; all criteria required.

Eligibility for Dengvaxia: Laboratory-confirmed previous dengue infection

Laboratory confirmation is required prior to vaccination; vaccination of dengue-naive individuals is contraindicated.

Eligibility for Dengvaxia: Member is living in a dengue-endemic area (e.g., U.S. territories such as American Samoa, Puerto Rico, U.S. Virgin Islands, and certain freely associated states)

Residence in an endemic area is required per CDC/FDA guidance.

Use of Dengvaxia is limited by the FDA indication and policy requirements. The vaccine is not appropriate for individuals who were not previously infected with dengue virus, for those who are outside the age range of 9 through 16 years, or for persons who do not live in a dengue endemic area. All other indications are considered investigational and may be denied.

Vaccination of individuals without laboratory evidence of prior dengue infection, or when prior infection status is unknown, is not medically necessary. The policy and FDA labeling state that Dengvaxia is not approved for use in dengue-naïve persons; vaccinating those without confirmed prior infection is associated with an increased risk of severe dengue upon subsequent infection.

Provider Actions, Authorization, and Documentation

Prior Authorization

Prior Authorization and Billing

Prior authorization requirements vary by plan. When prior authorization is required, include documentation of laboratory-confirmed prior dengue infection and member age. Use vaccine administration code 90587 for billing and follow plan-specific prior auth processes.

Affected code: 90587 (vaccine administration)
Prior authorization: check member-specific plan requirements

Step Therapy

No step therapy requirements are specified for Dengvaxia. Confirm laboratory evidence of prior dengue infection before vaccination as required by FDA/CDC guidance.

No step therapy or quantity limits specified
Ensure laboratory confirmation of prior infection before administering vaccine

Documentation Required

Required Documentation

Documentation must include laboratory confirmation of prior dengue infection per CDC-recommended testing and the member's age and residence in an endemic area.

Required: Laboratory-confirmed previous dengue infection (per CDC guidance)
Required: Member age documented (9 through 16 years)
Required: Evidence of living in a dengue-endemic area

Denial Risk

Triggers for Denial

Vaccination claims may be denied if any of the following apply.

Member is outside the approved age range (not 9 through 16 years)
No laboratory-confirmed prior dengue infection documented
Member does not live in a dengue-endemic area
Vaccination administered to a dengue-seronegative individual or when prior infection status is unknown

Background

Dengue is a mosquito-borne viral illness caused by one of four related serotypes; symptoms commonly include fever, rash, aches, nausea, and vomiting and typically last 2–7 days. There is no specific antiviral treatment, and prevention centers on avoiding mosquito bites and, in eligible populations, vaccination. Dengvaxia is the only dengue vaccine approved by the U.S. Food and Drug Administration and is recommended for routine use by ACIP only for individuals 9 through 16 years of age with laboratory-confirmed previous dengue infection who live in dengue endemic areas. Vaccinating persons who are dengue-naïve increases the likelihood of severe disease if they are later infected.

Definitions

Vaccine

DefinitionA vaccine is a preparation used to stimulate the body's immune response against diseases.

Typical administrationUsually administered by needle injection (some vaccines may be oral or intranasal).

PurposeUsed to prevent infectious diseases by inducing protective immunity prior to exposure.

Endemic area

U.S. territories specifiedAmerican Samoa, Puerto Rico, U.S. Virgin Islands.

Freely associated states includedFederated States of Micronesia, Republic of the Marshall Islands, Republic of Palau.

CDC recommendation contextCDC recommends dengue vaccination for these areas where dengue is endemic.