Pneumococcal Vaccines
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria for Pneumococcal Vaccination
Adults aged 65 years
Recommendations and sequencing noted in cited guidance
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
| 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). |
Provider Actions, Billing, and Documentation
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.
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.
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.
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.
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.
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.
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
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.
Background and Epidemiology
Streptococcus pneumoniae is a major cause of morbidity and mortality worldwide, responsible for clinical syndromes including pneumonia, bacteremia, and meningitis. Invasive disease rates are highest among young children and adults aged ≥65 years and are increased in persons with certain comorbid conditions; ACIP recommendations guide use of pneumococcal conjugate and polysaccharide vaccines to reduce these outcomes.
Definitions and Vaccine Descriptions
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