Pneumococcal Vaccines (CPB 0037, reviewed 2026-10-06)

Verify current applicability with Aetna: Confirm whether the practice has implemented this pneumococcal vaccine coverage policy and whether it supersedes any prior version. Billing team should: (1) Review coverage criteria for each age group and risk category to determine member eligibility before submitting claims for CPT codes 90671, 90677, 90684, and 90732; (2) Ensure medical necessity documentation in member records aligns with CDC/ACIP-stated conditions (risk conditions specified in Footnote 1 for ages 19-49 and Footnote 2 for children); (3) Implement sequential vaccination rules in billing workflows—specifically, PCV15 must be followed by PPSV23 (90732) at prescribed intervals for certain cohorts, while PCV20 or PCV21 do not require follow-up PPSV23; (4) Configure claims submission to reflect vaccine-specific sequencing rules and interval requirements; (5) Flag claims for members 65+ for shared decision-making review, as this population has discretionary coverage options per policy; (6) Confirm that quantitation of Streptococcus pneumoniae antibody (87652) is not billed for pneumococcal infection diagnosis, as the policy classifies this as experimental/unproven for that indication. Identify any discrepancies between this policy review and prior Aetna guidance to ensure compliance.