CurrentAetnaPolicy 0037

Pneumococcal Vaccines

Aetna's clinical policy on medical necessity and coverage of pneumococcal vaccines (PCV13, PCV15, PCV20, PPSV23) for children and adults, aligned to CDC/ACIP recommendations and affecting providers who administer or bill for these vaccines.

Policy Summary

PayerAetna

PolicyPneumococcal Vaccines

Policy CodePolicy 0037

Change TypeNo material change

Effective DateJul 21, 1995

Next Review DateJan 11, 2024

Key ActionVerify prior pneumococcal vaccination and intervals before administering additional doses to determine appropriate sequencing (PCV15 → PPSV23 or PCV20 alone).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=65 yrsAge threshold for universal adult recommendation

4PCV dosing schedule for infants

90670,90671,90677,90732Primary vaccine CPT/HCPCS codes listed

10/24/2023Most recent policy review

Coverage Criteria for Pneumococcal Vaccination

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ALL of the following

CDC recommends pneumococcal vaccination for all adults 65 years or older.
For adults 65 years or older who have not previously received any pneumococcal vaccine: 1 dose of PCV15 or PCV20 is recommended.
If PCV15 is used in adults ≥65 years, it should be followed by a dose of PPSV23 at least 1 year later (minimum interval 8 weeks may be considered for certain high-risk conditions such as immunocompromise, cochlear implant, or CSF leak).
If PCV20 is used in adults ≥65 years, a dose of PPSV23 is not indicated.
For adults ≥65 years who have only received PPSV23 previously, a single dose of PCV15 or PCV20 is recommended at least 1 year after the most recent PPSV23 dose.
For adults ≥65 years who have only received PCV13 previously, give PPSV23 as previously recommended; the incremental public health benefit of providing PCV15 or PCV20 after PCV13 (with or without PPSV23) has not been established.
If PCV13 was given but PPSV23 series is incomplete and PPSV23 is unavailable, one dose of PCV20 may be used to complete the pneumococcal vaccination series.

Evidence summaries

Clinical-effectiveness statements extracted from the background section

ALL of the following

A randomized placebo-controlled trial of PCV13 in ~84,500 adults aged ≥65 years showed no reduction in overall mortality or overall incidence of community-acquired pneumonia over an average 4-year follow-up; the number needed to vaccinate to prevent one case of vaccine-type pneumococcal pneumonia was approximately 1,000 (No authors listed, 2016).
Evidence for clinical protection against invasive pneumococcal disease (IPD) in solid organ transplant recipients and other immunocompromised populations is limited to immunogenicity and small trials; transplant recipients mount serologic responses but responses are generally lower than healthy controls and clinical efficacy data are lacking (Dendle et al., 2018).
Studies in rheumatoid arthritis patients indicate that certain immunosuppressive therapies (e.g., methotrexate, rituximab) reduce humoral responses to pneumococcal vaccination, whereas anti-TNF agents have less consistent impact (Hua et al., 2014).
For PPSV23, revaccination in immunocompetent persons previously vaccinated is generally not recommended; revaccination may be considered for selected high-risk individuals or immunocompromised patients due to waning immunity, but routine revaccination is not supported by high-quality evidence (PPSV23 background, Merck, 2021b; Chang et al., 2007).
There is insufficient evidence from randomized trials that routine pneumococcal vaccination reduces morbidity in bronchiectasis or cystic fibrosis populations; no RCTs were identified for CF and evidence is inadequate to draw firm conclusions (Cochrane reviews; Burgess and Southern, 2014; Chang et al., 2007).
PCV15 (Vaxneuvance) was noninferior to PCV13 in immunogenicity trials in infants, children, and adolescents and elicited comparable or higher responses for shared and unique serotypes; some diminished responses are seen in individuals with altered immunocompetence (Merk, 2022).
Prevnar 20 (PCV20) is licensed for adults as a single dose; effectiveness for prevention of pneumonia in individuals younger than 18 years has not been established in clinical trials (Wyeth Pharmaceuticals, 2023).

Billing and Coding

Covered CPT/HCPCS/ICD-10 codes (when selection criteria met)mixedCovered

90670	Pneumococcal conjugate vaccine, 13 valent, for intramuscular use.
90671	Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use.
90677	Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use.
90732	Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use.
90460	Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered.
90461	Each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure).
90471	Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid).
90472	Each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure).
G0009	Administration of pneumococcal vaccine.
G0310	Immunization counseling by a physician or other qualified health care professional when the vaccine(s) is not administered on the same date of service, 5 to 15 mins time (used for Medicaid billing purposes).

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Provider Actions, Billing, and Documentation

Prior Authorization

Verify Benefits / Prior Authorization

Check member benefits and verify any prior authorization requirements with Aetna before administering pneumococcal vaccines. This Clinical Policy Bulletin assists with administering benefits but does not itself specify plan-level prior authorization rules; providers are responsible for benefit verification.

Providers must verify prior authorization and coverage with the member's plan before vaccination.

Denial Risk

Experimental / Investigational Exclusion

Pneumococcal vaccines (PCV13, PCV15, PCV20, PPSV23) are considered experimental/investigational and may be denied when administered to groups not listed as medically necessary in Section I. Claims for populations outside the specified recommendations may be denied as not medically necessary.

Vaccination outside listed groups is considered experimental/investigational by Aetna and may not be covered.

Denial Risk

Contraindications for Prevnar 20

Prevnar 20 (PCV20) is contraindicated in individuals with a known allergy to any component of the vaccine or to diphtheria toxoid. Consult the vaccine prescribing information for additional warnings and precautions (e.g., apnea risk in certain premature infants).

Contraindication: Allergy to any component of Prevnar 20 or to diphtheria toxoid.
Review full prescribing information for pregnancy, lactation, and other warnings.

Billing Rule

Coding and Documentation

Use the listed CPT, HCPCS, and ICD-10 codes when billing for pneumococcal vaccination encounters and administration. Document the encounter with ICD-10 code Z23 and include appropriate vaccine CPT/HCPCS codes when selection criteria are met.

Covered CPT codes when selection criteria met: 90670, 90671, 90677, 90732.
Administration and counseling codes: 90460–90472 (as applicable) and 90471–90472; HCPCS administration code G0009.
ICD-10 code for encounter: Z23.

Documentation Required

Document Prior Vaccination and Indication

When administering pneumococcal conjugate vaccines to adults and children, document prior pneumococcal vaccination history and the clinical indication (age, risk conditions, immunocompromising status) that supports vaccine selection and sequencing per ACIP guidance.

Document prior vaccine history (PCV13, PCV15, PCV20, PPSV23) and dates.
Document patient risk status or indication for vaccination.

Documentation Required

Elective Splenectomy — Timing and Documentation

For elective splenectomy, document administration of pneumococcal, meningococcal, and Hib vaccines at least 14 days prior to surgery. If preoperative administration is not possible, document vaccination on or after postoperative day 14.

Administer and document pneumococcal, meningococcal, and Hib vaccines ≥14 days before elective splenectomy when possible.
If not given preoperatively, document administration on or after postoperative day 14.

Note

Vaccine Sequencing and Intervals

Follow ACIP sequencing guidance when selecting vaccines: PCV15 should be followed by PPSV23 (typically ≥1 year later; minimum 8 weeks in certain high‑risk or immunocompromised adults). PCV20 may be used alone without subsequent PPSV23. If PCV13 is used in shared clinical decision‑making for adults ≥65, administer PCV13 before PPSV23 and observe recommended intervals.

If PCV15 is administered, give PPSV23 at least 1 year later (minimum 8 weeks for certain high‑risk/immunocompromised adults).
If PCV20 is administered, PPSV23 is not routinely indicated.
When PCV13 is used in adults ≥65 by shared decision‑making, give PCV13 before PPSV23 and maintain the recommended intervals.

Step Therapy

Step‑Therapy

No step‑therapy requirements are described in this Clinical Policy Bulletin. Providers should follow ACIP recommendations and plan coverage rules; verify any utilization management requirements with the payer.

There are no step‑therapy requirements specified in this policy.
Verify any plan-specific utilization management policies with Aetna.

Definitions and Vaccine Descriptions

inv-31: Pneumococcal vaccines — Two types available in the U.S.: PCV (PCV13, PCV15, PCV20) and PPSV23

Vaccine types available in U.S.Two types: pneumococcal conjugate vaccines (PCV13, PCV15, PCV20) and pneumococcal polysaccharide vaccine (PPSV23).

PCV examplesPCV13 (Prevnar 13), PCV15 (Vaxneuvance), PCV20 (Prevnar 20).

PPSV examplePPSV23 (Pneumovax 23) — polysaccharide vaccine covering 23 serotypes.

inv-32: PPSV23 / PCV — PPSV23 (Pneumovax 23) is a 23-valent polysaccharide vaccine; PCV13/15/20 described

PPSV23 descriptionPneumovax 23 is a 23-valent purified capsular polysaccharide vaccine (PPSV23) indicated for persons ≥50 years and persons ≥2 years at increased risk; not approved for children <2 years.

PPSV23 serotype coverageContains antigens for 23 S. pneumoniae serotypes (1,2,3,4,5,6B,7F,8,9N,9V,10A,11A,12F,14,15B,17F,18C,19F,19A,20,22F,23F,33F).

PCV general notePCVs are conjugate vaccines (PCV13, PCV15, PCV20) with varying serotype coverage and age indications per FDA labeling.

inv-33: PCV15 (Vaxneuvance) — 15-valent conjugate vaccine; noninferiority and immunogenicity findings referenced

Vaccine identityPCV15 (Vaxneuvance) is a 15-valent pneumococcal conjugate vaccine supplied as a 0.5 mL single-dose prefilled syringe for intramuscular injection and approved for individuals 6 weeks of age and older.

Immunogenicity findingsPCV15 was found noninferior to Prevnar 13 in infants, children and adolescents; higher immune responses were observed for unique serotypes 22F and 33F in studies.

Immune response cautionSome individuals with altered immunocompetence may have reduced immune responses to Vaxneuvance.

inv-34: PCV20 (Prevnar 20) — 20-valent conjugate vaccine contains PCV13 serotypes plus seven additional serotypes

Vaccine identityPCV20 (Prevnar 20) is a 20-valent pneumococcal conjugate vaccine supplied as a 0.5 mL single-dose prefilled syringe for intramuscular injection.

Serotype compositionContains the 13 serotypes in PCV13 plus seven additional serotypes: 8, 10A, 11A, 12F, 15B, 22F, and 33F.

Approval basisFDA approvals for adults were supported by Phase 1–3 trials (>6,000 adult subjects); pediatric approval based on phase 2/3 trials; some adult pneumonia indications approved under accelerated approval based on OPA immune responses.

inv-35: PCV7 — 7-valent pneumococcal conjugate vaccine (CRM197-conjugated)

Vaccine identityPCV7 is a 7-valent pneumococcal conjugate vaccine (CRM197-conjugated) used historically with modest benefit for AOM prevention in healthy infants.

AOM evidencePCV7 showed modest beneficial effects in healthy infants with low baseline risk of acute otitis media; no benefit observed when given to high-risk infants after early infancy or to older children with prior AOM.

inv-36: PCV13 / PCV15 / PCV20 — 13-, 15-, and 20-valent conjugate vaccines referenced as licensed/approved formulations

Licensed conjugate vaccinesPCV13 (Prevnar 13), PCV15 (Vaxneuvance), and PCV20 (Prevnar 20) are licensed/approved conjugate vaccine formulations in the U.S. with specified age and indication labeling.

PCV13 indicationsPrevnar 13 is FDA‑approved for children 6 weeks through 17 years and for adults 18 years and older for prevention of invasive disease and (in adults) pneumonia for listed serotypes.

PCV15 and PCV20 approvalsPCV15 approved for individuals ≥6 weeks for prevention of invasive disease for listed serotypes; PCV20 approved for individuals ≥6 weeks for IPD and for adults ≥18 for pneumonia with some indications under accelerated approval.

OpenPayer

Pneumococcal Vaccines

Coverage Criteria for Pneumococcal Vaccination

Billing and Coding

Provider Actions, Billing, and Documentation

Background and Epidemiology

Definitions and Vaccine Descriptions