All PlansCoverageMedium impact
Diphtheria, Tetanus, and Pertussis Vaccines (CPB 0653, reviewed 2025-12-08)
Aetna·Pediatrics, Family Medicine, General Practice +4 more·Medical Policy
We identified it
Aug 13, 2026
Summary
Aetna has reaffirmed its medical necessity coverage for diphtheria, tetanus, and pertussis vaccines across multiple formulations (DTaP, Tdap, and combination vaccines) for eligible age groups and clinical scenarios, including booster immunization in adults 10+ years, pregnant women, and post-partum women. This policy establishes specific CPT codes for each vaccine formulation and includes coverage for tetanus toxoid-containing immunizations for wound treatment. The policy applies nationally and affects pediatric, adult, and preventive care billing.
Action Required
Billing team must ensure claims for diphtheria, tetanus, and pertussis vaccines use the correct CPT codes based on patient age and vaccine formulation: CPT 90700 for DTaP (under 7 years), CPT 90715 for Tdap (7 years and older), CPT 90696 for DTaP-IPV (ages 4-6), CPT 90697 for DTaP-IPV-Hib-HepB (ages 6 weeks-4 years), CPT 90723 for DTaP-HepB-IPV (ages 6 weeks-4 years), CPT 90702 for DT (under 7 years), and CPT 90714 for Td preservative-free (7 years and older). Use CPT 90471/90472 for administration. Include ICD-10 code Z23 (Encounter for immunization) for all preventive vaccine claims. For wound-related tetanus toxoid immunization, use appropriate diagnosis codes (S00-S99 range for injuries). Verify patient age eligibility before billing Tdap for patients 10-64 years (Adacel) versus 65+ years (Boostrix preferred). Update billing system templates to reflect specific vaccine formulation requirements and age-appropriate code selection. No prior authorization is indicated in this policy; all listed vaccines are covered when administered per ACIP recommendations.