Code only when selection criteria are met

Code vaccine and administration claims only when the patient's condition meets the policy's ACIP-based selection criteria; use the listed CPT vaccine codes (90636, 90739–90748) and HCPCS administration code (G0010) corresponding to the service rendered.

• Covered CPT vaccine codes: 90636, 90739–90748
• Covered HCPCS administration code: G0010
• Billing must be supported by an appropriate ICD-10 diagnosis/encounter code listed in the policy

Use listed FDA‑approved HepB products; Heplisav‑B pregnancy note

Use FDA‑approved hepatitis B vaccine products listed in the policy when vaccinating; note that Heplisav‑B (HepB‑CpG) is approved for adults ≥18 years as a 2‑dose (1 month) series and has not been tested in pregnancy — use an alternate vaccine for pregnant patients.

• FDA‑approved single‑antigen vaccines: Engerix‑B, Recombivax HB
• Heplisav‑B: indicated for adults ≥18; 2‑dose schedule; safety not tested in pregnancy
• Other approved products: PreHevbrio, Pediarix, Twinrix, Vaxelis

No clinical prior authorization specified

No prior authorization requirements are specified in the clinical policy sections that define medical necessity and revaccination; providers should follow the clinical criteria described for coverage.

No explicit prior‑auth codes or requirements in this section

This policy section contains no explicit prior authorization codes or additional prior‑authorization requirements; submit claims with appropriate supporting documentation per policy criteria.

Revaccination guided by anti‑HBs <10 mIU/mL in specified groups

Revaccination/booster dosing decisions are guided by anti‑HBs levels (<10 mIU/mL) in specified populations (infants of HBsAg‑positive mothers, hemodialysis patients, other immunocompromised persons, and health care personnel) per CDC/ACIP guidance.

• Anti‑HBs threshold prompting revaccination: <10 mIU/mL
• Follow CDC/ACIP revaccination algorithms for each population described

Stepwise revaccination: booster then testing, then complete series if needed

For infants of HBsAg‑positive mothers and for health care personnel with anti‑HBs <10 mIU/mL, the policy describes giving a single additional (booster) dose, retesting in 1–2 months, and completing a second series if antibody remains <10 mIU/mL.

• Infants: single revaccination dose → retest 1–2 months; if still <10 mIU/mL give two additional doses or a second 3‑dose series and retest
• HCP: additional dose → retest 1–2 months; if still <10 mIU/mL complete second series (usually total 6 doses) and retest

No step therapy sequences required

No step therapy (sequenced medication/vaccine trial) requirements are described in the policy; revaccination decisions are based on antibody testing and population‑specific CDC recommendations rather than step sequences.

No step therapy requirements in this section

There are no step therapy requirements specified in this portion of the document; follow the testing‑based revaccination guidance instead.

Accept dated records; document anti‑HBs <10 mIU/mL to justify revaccination

Accept dated vaccination records as evidence of prior HepB vaccination; use documented anti‑HBs testing showing <10 mIU/mL to support need for revaccination in the specified groups.

• Providers should accept dated records as proof of prior HepB vaccination (Weng et al, 2022)
• Anti‑HBs <10 mIU/mL used to determine revaccination need per ACIP/Aetna policy

Record and antibody documentation required for revaccination decisions

Providers should accept dated immunization records as evidence of prior HepB vaccination; for selected populations, document anti‑HBs titers and note values <10 mIU/mL to guide revaccination decisions.

• Dated vaccination records constitute acceptable evidence
• Use anti‑HBs titers (<10 mIU/mL) to document lack of protective antibody when indicated

Document maternal HBsAg status and infant HBIG/HBV vaccine timing (≤12 hours)

For perinatal prophylaxis cases, document the mother's HBsAg status and the infant's receipt and timing of HBIG and hepatitis B vaccine — the policy specifies administration within 12 hours of birth per CDC guidance.

• Document maternal HBsAg test result
• Document administration of HBIG and hepatitis B vaccine to the newborn and that it occurred within 12 hours of birth

Use Aetna resources for plan‑specific documentation guidance

Refer to Aetna resources listed in the policy (glossary, mobile app, FAQs, program provisions and legal notices) for plan‑specific documentation and administrative guidance.

• Aetna Glossary and FAQs links
• Aetna Mobile App and Program Provisions/legal notices

Travel or work‑required immunizations generally not covered — verify contract

Vaccinations required solely for travel or because of work‑related risk are generally not covered under Aetna — verify member contract language, limitations, and exclusions before billing.

• Check member contract language for coverage of travel‑ or work‑required immunizations

Revaccination indicated only for specified groups; not for routinely vaccinated healthy persons

Revaccination is generally not recommended for persons with normal immune status who completed the primary series; revaccination is indicated only for specified groups such as infants of HBsAg‑positive mothers, HCP, and hemodialysis patients when anti‑HBs <10 mIU/mL.

• Booster doses for persons with normal immune status are considered not medically necessary
• Revaccination indicated for listed high‑risk groups when anti‑HBs <10 mIU/mL

Failure to provide timely perinatal prophylaxis risks rejection/denial

Failure to identify HBsAg‑positive pregnant women and not providing HBIG plus hepatitis B vaccine to the newborn within the recommended timing (within 12 hours of birth) could be inconsistent with CDC guidance and risk denial if plan requires adherence to standard preventive protocols.

Administrative disclaimer — not a contract or clinical authorization

This clinical policy bulletin does not constitute a contract and does not provide clinical authorization criteria; it contains an administrative disclaimer that it is a general description of benefits.