All PlansCoverageMedium impact
Respiratory Syncytial Virus (RSV) Vaccines for Adult and Maternal Use (CPB 1027, reviewed 2026-10-09)
Aetna·Allergy & Immunology, Family Medicine, Geriatrics +5 more·Medical Policy
We identified it
Oct 10, 2026
Summary
Aetna's CPB 1027 establishes coverage criteria for RSV vaccines (Arexvy, Abrysvo, mRESVIA) for adults 75+, adults 50-74 with increased risk, and pregnant women at 32-36 weeks gestation. Billing teams must verify patient age, risk status, or gestational age before submitting claims using the specified CPT and ICD-10 codes to avoid denial for non-covered indications.
Action Required
Billing team should verify RSV vaccine eligibility criteria before claim submission: (1) confirm patient age (75+ years) or (2) document increased risk of severe RSV disease for ages 50-74, or (3) verify gestational age 32-36 weeks for pregnant patients receiving Abrysvo only. Update claim submission workflows to cross-reference patient demographics against policy criteria in CPB 1027 to prevent denials for non-covered indications (e.g., patients under 50 without risk factors, pregnant patients outside 32-36 week window, or revaccination attempts). Ensure ICD-10 code Z29.11 is used only for qualifying ages/conditions and that gestational age codes Z3A.32-Z3A.36 are reserved for pregnant member claims only.