CommercialCoverageMedium impact
Diphtheria, Tetanus, and Pertussis Vaccines (CPB 0653, reviewed 2026-09-25)
Aetna·Pediatrics, Family Medicine, General Practice +3 more·Medical Policy
We identified it
Sep 30, 2026
Summary
Aetna has updated its medical policy (CPB 0653) on diphtheria, tetanus, and pertussis vaccines, affirming coverage for FDA-approved DTaP, Tdap, and Td vaccines across all age groups and indications per CDC/ACIP recommendations. The policy includes specific coverage for combination vaccines (Pediarix, Pentacel, Vaxelis, Kinrix, Quadracel) and acceptable alternatives (Boostrix, Adacel, Tenivac), with detailed CPT codes and ICD-10 codes for immunization encounters and wound management scenarios.
Action Required
Billing team: Verify that your billing system and encounter templates include all covered CPT codes (90471, 90472, 90700, 90715, 90696, 90697, 90723, 90714, 90698) and ICD-10 code Z23 for Aetna claims. Ensure vaccine administration claims for DTaP (ages <7), Tdap (ages ≥7), and Td vaccines are submitted with correct age-based codes and medical necessity documentation supporting CDC/ACIP indications (routine series, catch-up vaccination, booster every 10 years, pregnancy, or wound management). For wound management claims, include applicable injury/burn ICD-10 codes (S00-S99, T20-T32 ranges) along with Z23. Update provider documentation templates to capture indication at time of service. No prior authorization is mentioned; claims should process as preventive services.