Diphtheria, Tetanus, and Pertussis Vaccines
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Defines Aetna's medical necessity coverage for diphtheria, tetanus, and pertussis vaccines, including specific combination products, booster doses, wound management indications, and adherence to ACIP recommendations; applies to Aetna members (national policy).
No material clinical or coverage changes in this revision.
Coverage Criteria for Diphtheria, Tetanus, and Pertussis Vaccines
inv-01: Medically Necessary Vaccines and Indications
Aetna considers the following vaccines medically necessary:
Enumerated as distinct covered indications in policy.
inv-02: Schedule, Catch-up, Pregnancy, and Wound Management Guidance
ACIP-derived scheduling and catch-up guidance referenced as coverage context:
From ACIP routine schedule.
Preferred catch-up schedule per ACIP.
ACIP recommendation included in policy.
Wound management details provided.
inv-03: Indications: Wound management and Pregnancy
Covered when meeting ACIP/clinical indications described below:
Includes TIG dosing and indications.
ACOG/ACIP pregnancy guidance.
inv-04: Vaccine Product Use
Vaccine-specific administration/use covered statements:
Product-specific interchangeability and mixed-sequence data are limited; follow manufacturer guidance.
ACIP decennial booster guidance.
Product approvals and 2019 Adacel labeling changes noted.
inv-05: Routine maternal Tdap administration
Covered when ALL of the following are met
If not administered during pregnancy, give immediately postpartum if the woman has never received prior Tdap.
inv-06: Exceptions and alternative timing
Covered when ANY of the following indications apply
Policy acknowledges specific scenarios where timing outside the preferred window is appropriate.
The older whole-cell DTP vaccine has been replaced by acellular pertussis-containing formulations. As noted in the policy background, DTP is no longer recommended and DTaP (acellular pertussis) is preferred for the childhood five-dose primary and booster series because it is associated with fewer side effects. DT remains available only for children 6 weeks through 6 years who should not receive pertussis-containing vaccines.
The policy therefore specifies coverage for modern acellular pertussis vaccines (DTaP and Tdap) and their approved combination formulations per ACIP/labeling, and indicates that whole-cell DTP is not recommended for routine use.
Manufacturers’ product information indicates that some combination vaccine interchangeability and mixed-sequence use have limited or no safety/immunogenicity data. For example, Pentacel and Daptacel contain different amounts of pertussis antigens and data are not available on the safety and immunogenicity of mixed Pentacel–Daptacel sequences for successive primary doses. Similarly, Vaxelis labeling states that data are not available on safety or effectiveness when used following 1 or 2 doses of DTaP from a different manufacturer.
Because these mixed-sequence data are limited, the policy documents caution about extrapolating immunogenicity and safety across manufacturers for successive doses of combination DTaP-containing vaccines and recommends following product-specific guidance when completing primary or booster series.
Within the extracted policy text there are no explicit exclusions stated for the covered tetanus, diphtheria, and pertussis vaccines. The document focuses on ACIP-recommended indications, timing (including pregnancy), product-specific use, and situations such as wound management rather than listing specific non-covered scenarios.
The policy emphasizes routine maternal Tdap administration during each pregnancy in the recommended window of 27–36 weeks’ gestation to maximize neonatal passive antibody protection. It notes Tdap is safe in pregnancy and should be given as early in that window as possible.
Supporting evidence cited in the background indicates that Tdap given pre-conception or in early pregnancy may result in lower pertussis-specific antibody levels in infants compared with third-trimester maternal immunization. Healy et al. (2013) found infants of mothers immunized pre-conception or in early pregnancy had estimated pertussis toxin IgG levels often below assay quantitation by age 2 months, suggesting third-trimester immunization better supports infant antibody levels and underpins the recommendation for vaccination at 27–36 weeks.
Billing and Diagnosis Codes
| 90471 | Immunization administration; one vaccine (single or combination vaccine/toxoid). |
| 90472 | Each additional vaccine (single or combination vaccine/toxoid). |
| 90700 | Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use. |
| 90715 | Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use. |
| 90696 | DTaP-IPV (Diphtheria, tetanus toxoids, acellular pertussis and inactivated poliovirus vaccine), when administered to children 4 through 6 years of age, for intramuscular use. |
| 90697 | Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenzae type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for intramuscular use. |
| 90698 | Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae type b, and inactivated poliovirus vaccine (DTaP-IPV/Hib), for intramuscular use. |
| 90723 | Diphtheria, tetanus toxoids, and acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DtaP-HepB-IPV), for intramuscular use. |
| Z23 | Encounter for immunization. |
Provider Actions, Billing & Documentation Requirements
Billing codes to use — Immunization administration and vaccine product codes
Billing: Providers must bill the exact immunization administration and vaccine product CPT/HCPCS codes listed for the covered vaccines. Use 90471 for the first vaccine administration and 90472 for each additional vaccine administered during the same encounter. Use the product-specific CPT/HCPCS codes shown (e.g., 90700, 90702, 90714, 90715, 90696, 90697, 90723 as applicable). Include ICD-10 code Z23 (Encounter for immunization) when documenting routine immunization encounters.
Prior authorization — None required
Prior authorization: No prior authorization requirement is specified for administration of DTaP/Tdap/Td vaccines in this policy. Providers should follow clinical indications and vaccine-preference guidance rather than submit prior authorization.
- No PA required per this section.
Wound-related coding requirements
Wound-related coding requirements: When immunization is provided for wound management, include appropriate ICD-10 injury/wound codes documenting the type and location of the wound (example ranges: S00–S99 and selected T-codes as applicable). Also include documentation that supports the clinical indication for tetanus prophylaxis.
- Use relevant ICD-10 injury codes (e.g., S01.x, S10.x ranges shown in policy) to document the wound.
- Include supporting diagnosis codes alongside Z23 when immunization is for wound management.
Wound management timing and vaccine preference for wound indications
Wound management timing: Document that >5 years have elapsed since the last tetanus-toxoid containing vaccine when administering a tetanus toxoid-containing vaccine for wound management. For persons ≥11 years without prior documented Tdap or with unknown Tdap history, Tdap is preferred. For pregnant women requiring tetanus prophylaxis, use Tdap.
- Confirm and document interval since last tetanus-containing dose (>5 years for wound indication).
- If patient ≥11 years and Tdap history absent/unknown, preferentially administer Tdap.
- For pregnant patients requiring tetanus prophylaxis, administer Tdap.
No step therapy or additional PA/documentation requirements specified
Provider actions not otherwise specified in this section: No step therapy requirements or other utilization management (beyond standard coding/documentation) are described in this section. Also, there are no additional documentation or prior authorization requirements specified in the extracted text beyond those listed.
- No step therapy requirements described.
- No additional prior authorization or documentation requirements specified here beyond coding and clinical documentation guidance.
Required diagnostic documentation
Required diagnostic documentation: Document the encounter reason (Z23 for immunization) and, when relevant, the specific wound/injury ICD-10 code(s) supporting wound management (include type and contamination status).
- Include Z23 for routine immunization encounters.
- When immunizing for wound management, document the specific wound ICD-10 code(s) (type/location).
- Document wound contamination status if applicable.
Required documentation — Immunization, wound, and pregnancy details
Required documentation: Record immunization history (including prior Tdap or tetanus-containing vaccines), date of last tetanus-toxoid containing vaccine, wound type and contamination status for wound-related indications, and gestational timing when vaccinating pregnant patients. For pregnancy, document the gestational age and that Tdap was given ideally at 27–36 weeks’ gestation (or the clinical reason if given outside that window).
- Immunization history and dates (including prior Tdap).
- Date of last tetanus-toxoid containing vaccine (to establish >5 years for wound indication).
- Wound type and contamination status when relevant.
- Pregnancy: gestational age at vaccination and indication if given outside 27–36 weeks.
Document maternal Tdap administration timing
Document maternal Tdap administration timing: For pregnant women, document that Tdap was administered at 27–36 weeks’ gestation (preferably earlier in that window). If Tdap was given earlier in pregnancy or postpartum due to extenuating circumstances (wound, outbreak, etc.), document the reason; repeat vaccination during 27–36 weeks is not required if already given during the current pregnancy.
- Record gestational age/date of Tdap administration.
- If administered outside 27–36 weeks, document clinical justification (wound management, outbreak, etc.).
- Do not revaccinate during 27–36 weeks if Tdap already given during the same pregnancy.
Vaccine preference guidance — Tdap vs Td and catch-up sequencing
Vaccine preference guidance: For persons ≥11 years who require a tetanus toxoid-containing vaccine and have no prior Tdap or unknown Tdap history, preferentially use Tdap. For pregnant women, Tdap should be used during each pregnancy (27–36 weeks preferred). For nonpregnant persons with documented prior Tdap, either Td or Tdap may be used when indicated. For catch-up schedules in persons 7–18 years, preferred sequence is Tdap first, then Td or Tdap ≥4 weeks later, then Td or Tdap 6–12 months later.
- Prefer Tdap for ≥11 years with absent/unknown Tdap history.
- Administer Tdap to pregnant women during each pregnancy (27–36 weeks preferred).
- If prior Tdap documented in nonpregnant adults, either Td or Tdap may be used for boosters.
- Catch-up for 7–18 years: Tdap → Td/Tdap ≥4 weeks → Td/Tdap 6–12 months later.
Background and Rationale
Vaccines are available to protect against diphtheria, tetanus and pertussis. The policy references the range of licensed products: DT/ Td formulations for diphtheria and tetanus alone; DTaP formulations for the pediatric five-dose series (examples include Daptacel, Infanrix, Pentacel, Pediarix, Quadracel, Vaxelis); and Tdap boosters for older children, adolescents and adults (Adacel, Boostrix).
ACIP-recommended routine childhood DTaP schedule is described in the policy as primary doses at 2, 4, and 6 months with boosters at 15–18 months and 4–6 years. For adults and adolescents, Tdap is recommended as the booster formulation, and maternal Tdap is recommended during each pregnancy (preferred at 27–36 weeks’ gestation) to protect newborns via transplacental antibody transfer.
Definitions
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