CurrentAetnaPolicy 0402

Polio Vaccine

Defines Aetna's medical necessity determination that polio vaccine (primarily inactivated poliovirus vaccine, IPV) is a medically necessary preventive service when administered according to CDC/ACIP recommendations, including routine childhood schedule, special OPV exceptions, and adult primary immunization for those at increased risk of exposure. Notes plan-level exclusions for travel/work-related immunizations.

Policy Summary

PayerAetna

PolicyPolio Vaccine

Policy CodePolicy 0402

Change TypeNo material change

Effective DateMar 7, 2000

Next Review DateApr 25, 2024

Key ActionProviders must administer IPV according to ACIP-recommended schedules and document timing, indication (routine, travel, occupational risk, outbreak), and counseling when OPV is used due to parental refusal of IPV.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

4Routine childhood IPV doses

3Adult primary series doses

3OPV-use situations

2ICD-10 codes listed

Coverage Summary

Defines Aetna's medical necessity determination that polio vaccine (primarily inactivated poliovirus vaccine (IPV)) is a medically necessary preventive service when administered according to CDC/ACIP recommendations, including the routine childhood schedule, specified exceptions permitting oral poliovirus vaccine (OPV), and adult primary immunization for those at increased risk of exposure. Policy stance: covered_with_criteria when ACIP-recommended criteria are met.

Note: Some Aetna plans exclude coverage of immunizations required for travel or because of work-related risk; providers should check member benefit plan descriptions before administration. The policy aligns with CDC/ACIP guidance on use of IPV as routine vaccination.

Medical-Necessity Criteria

Medical Necessity - Routine childhood vaccination

Covered when ALL of the following ACIP-recommended schedule criteria are met:

ALL of the following

Administer inactivated poliovirus vaccine (IPV) as routine childhood vaccination
Schedule of 4 doses at ages: 2 months, 4 months, 6 to 18 months, and 4 to 6 years

Medical Necessity - Use of oral poliovirus vaccine (OPV)

OPV (oral polio vaccine) may be used ONLY in the following special circumstances (ANY of):

ANY of the following

Children of parents who are not willing to have their child receive the recommended injectable form of vaccine (OPV may be given only for the 3rd or 4th dose or both) and provider must discuss risk of vaccine-associated paralytic polio (VAPP) with parents/caregivers
Mass vaccination campaigns to control outbreaks of paralytic polio
Unvaccinated children who will be traveling in less than 4 weeks to areas where polio is endemic

Medical Necessity - Adults at increased risk

Covered when ALL of the following apply for adults (>18 years) at increased risk of exposure:

ALL of the following

Primary immunization with IPV is recommended for adults at increased risk of exposure
Risk groups include ONE of
- Health-care workers in close contact with individuals who may be excreting wild polioviruses
- Individuals who are members of specific population groups during an outbreak of polio caused by wild polioviruses
- Laboratory workers handling specimens which may contain polioviruses

Timing / interval criteria

ACIP minimum age and interval requirements (ALL):

ALL of the following

Minimum age for dose 1 is 6 weeks
Minimum interval between doses 1 and 2 and between doses 2 and 3 is 4 weeks
Minimum interval between doses 3 and 4 is 6 months
Final dose in IPV series should be administered at age 4 through 6 years, regardless of number of previous doses before the 4th birthday, and at least 6 months since the last dose
Minimal age and intervals may be used when imminent threat of exposure exists (e.g., travel to endemic/epidemic area)

Coding

Covered CPT / HCPCS codes when selection criteria are metCPT|HCPCSCovered

90698	Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae type b, and inactivated poliovirus vaccine (DTaP-IPV/Hib), for intramuscular use
90713	Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular use
90723	Diphtheria, tetanus toxoids, acellular pertussis vaccine, hepatitis B, and inactivated poliovirus vaccine (DTaP-HepB-IPV), for intramuscular use

Relevant ICD-10 codes for encounters/exposureICD-10

Z20.89	Contact with and (suspected) exposure to other communicable diseases [poliomyelitis]
Z23	Encounter for immunization

Provider Actions

Documentation Required

Follow ACIP schedule and document indication

Providers must administer IPV according to ACIP-recommended schedules and document the timing of doses, the clinical indication (routine childhood, travel, occupational risk, outbreak), and counseling provided when OPV is used due to parental refusal of IPV.

90713
90698
90723
Z20.89
Z23

Prior Authorization

Check plan exclusions for travel/work-related immunizations

Some Aetna plans exclude coverage of immunizations required for travel or because of work-related risk. Check the member's benefit plan description prior to administration to determine coverage or exclusions at the plan level.

Plan-level check — no specific codes

Billing Rule

Use appropriate CPT/HCPCS for IPV or combination vaccines

Report the specific CPT/HCPCS code that corresponds to the vaccine product administered. Use the code for IPV alone or the appropriate combination vaccine code as applicable.

90713
90698
90723

Background, Evidence & Definitions

Background: The policy aligns with CDC/ACIP recommendations favoring inactivated poliovirus vaccine (IPV) for routine childhood vaccination to eliminate the risk of vaccine-associated paralytic polio (VAPP); oral polio vaccine (OPV) is reserved for limited special circumstances. ACIP emphasizes a booster dose at greater than or equal to 4 years and specifies minimum intervals (including extending the minimum interval between dose 3 and dose 4 to 6 months). Inactivated poliovirus vaccine may be given concurrently with other vaccines, and when IPV and DTaP/DTP are administered together they should be given in separate syringes because of possible interference.

Source	Summary
ACIP/CDC recommendation	ACIP/CDC: Routine childhood polio vaccination recommends injectable inactivated poliovirus vaccine (IPV) with 4 doses at ages 2 months, 4 months, 6–18 months, and 4–6 years; OPV is reserved only for special circumstances (parental refusal of IPV for 3rd or 4th dose after counseling on VAPP, mass outbreak campaigns, or unvaccinated children traveling to endemic areas).
Clinical trials	nOPV2 phase II randomized controlled trial (Zaman et al. 2023): in poliovirus vaccine–naive newborns, nOPV2 was well tolerated and immunogenic with two doses (at birth and 4 weeks), yielding ~99% with protective neutralizing antibodies by week 8; supports note about novel OPV2 tolerability and immunogenicity.

Definitions:

IPV — Inactivated poliovirus vaccine (injectable).

OPV — Oral poliovirus vaccine (live attenuated).

VAPP — Vaccine-associated paralytic polio.

OpenPayer

Polio Vaccine

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions

Background, Evidence & Definitions

Revision History