Hepatitis A Vaccine — CPB 0048 | AETNA Coverage Update

Aetna modified CPB 0048 covering hepatitis A vaccine coverage, effective September 26, 2025. Here's what changes for billing teams.

Aetna, a CVS Health company, updated Clinical Policy Bulletin 0048 governing hepatitis A vaccine reimbursement. The policy covers CPT codes 90632, 90633, 90634, and 90636 across a broad range of at-risk populations — from children as young as 12 months to adults with chronic liver disease, HIV, or a history of homelessness. If your practice bills these codes for Aetna members, the updated criteria affect how you document medical necessity and which diagnoses support your claims.

Quick-Reference Table

Aetna Hepatitis A Vaccine Coverage Criteria and Medical Necessity Requirements 2025

The Aetna hepatitis A vaccine coverage policy aligns with CDC Advisory Committee on Immunization Practices (ACIP) and American Academy of Pediatrics (AAP) recommendations. Aetna treats HepA vaccination as a medically necessary preventive service — not a discretionary benefit — for a defined set of at-risk populations.

Medical necessity is met for all children aged 12 to 23 months. Children and adolescents aged 2 to 18 years who haven't previously received the HepA vaccine series also qualify. This is a catch-up provision, and it's worth making sure your eligibility checks flag unvaccinated older kids — not just infants.

Adults and special populations covered under this policy include individuals with chronic liver disease. That includes hepatitis B (HBV), hepatitis C (HCV), cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, and any patient with ALT (CPT 84466) or AST (CPT 84450) levels persistently greater than twice the upper limit of normal. If you're running those labs and seeing elevated results, the documentation already supports vaccination coverage.

HIV-positive individuals aged one year or older qualify regardless of their CD4 count or level of immune suppression. Hematopoietic cell transplant (HCT) recipients — billed under CPT 38240 or 38241 — may be vaccinated or revaccinated after transplant regardless of stem cell source. Liver transplant candidates aged 12 months or older are also covered.

Beyond clinical diagnoses, the policy covers several social and behavioral risk groups. These include:

Post-exposure prophylaxis is also covered. Aetna considers hepatitis A vaccine medically necessary when initiated within two weeks of HAV exposure. Document the exposure encounter clearly — claim denial risk is real if the timing or exposure context isn't captured.

Pregnant women at risk for HAV infection qualify as well. That includes pregnant patients who are international travelers, use drugs, have occupational risk, anticipate adoptee contact, experience homelessness, have chronic liver disease, or have HIV. Use the appropriate O98.4xx or O98.7xx ICD-10 codes for these claims.

One note on prior authorization: this policy does not list a prior authorization requirement for hepatitis A vaccine. However, individual Aetna HMO plan benefit designs may exclude travel and occupational immunizations. Always check the member's specific plan before billing CPT 90632 or 90633 for a traveler or lab worker — plan-level exclusions can trigger a claim denial even when the clinical criteria are met.

Aetna Hepatitis A Vaccine Exclusions and Non-Covered Indications

There are no "experimental or investigational" designations in CPB 0048 for hepatitis A vaccine. Coverage exclusions here are plan-level, not clinical.

Aetna HMO plans frequently exclude immunizations required for travel or work. If a member's HMO benefit document lists this exclusion, CPT 90632 or 90634 billed for a traveler or primate-animal handler won't be covered — even though the policy criteria are met. The clinical eligibility and the benefit design are two separate questions. Confirm both before the encounter.

The policy also notes that patients do not need to disclose their risk factor to receive the vaccine. ACIP explicitly states that any person who hasn't completed the HepA series may receive it. For billing purposes, this matters: you can bill with Z23 (encounter for immunization) when no specific risk factor is documented. You don't need to capture a behavioral or social history code to support the claim — though doing so strengthens the record.

Coverage Indications at a Glance

Aetna Hepatitis A Vaccine Billing Guidelines and Action Items 2025

1. Audit your CPT selection before September 26, 2025.
The policy covers four distinct CPT codes, and the wrong one will deny. Use 90633 for the pediatric/adolescent 2-dose schedule and 90634 for the 3-dose schedule. Use 90632 for adults. Use 90636 only for the combined HepA-HepB adult vaccine (Twinrix). Mixing these up is a common source of avoidable claim denial.

2. Map your ICD-10 codes to the correct risk-group documentation.
Review the 93 ICD-10 codes in this policy. For chronic liver disease patients, confirm you're using the specific codes: K70.x for alcoholic liver disease, K73.x–K74.x for fibrosis and cirrhosis, K75.4 for autoimmune hepatitis, K75.81 for NASH, and K76.0 for fatty liver. A claim billed with only a hepatitis A vaccine CPT and no supporting diagnosis — or the wrong diagnosis — is a denial waiting to happen.

3. Add Z23 to your charge capture template for preventive vaccine encounters.
When no specific risk factor is documented, Z23 (encounter for immunization) supports the claim. Aetna's own policy notes that risk factor disclosure isn't required. Your billing guidelines should reflect this — don't leave money on the table by waiting for a behavioral health or social history code that the patient never disclosed.

4. Verify HMO plan benefit documents before billing travel or occupational vaccine codes.
For CPT 90632 billed to an Aetna HMO member for travel or work-related indications, check the benefit description first. The medical necessity criteria under CPB 0048 are met — but the plan benefit may exclude those indications anyway. This distinction is critical. A medically necessary service can still be non-covered if the benefit design excludes it. Don't wait for a denial to find this out.

5. Document transplant status and post-exposure timing precisely.
For HCT patients billed under CPT 38240 or 38241, note the transplant date and confirm the vaccination is post-HCT. For post-exposure claims coded with Z20.828, the chart must show the exposure event and the vaccine administration date. Aetna's two-week window is hard. If day 15 hits before the vaccine is given, the post-exposure indication no longer applies.

6. Flag pregnant patients at risk during intake.
OB/GYN and maternal-fetal medicine billing teams should build a workflow to capture HAV risk factors during prenatal intake. Chronic liver disease, HIV (O98.711–O98.719), and travel during pregnancy all qualify. Documenting and billing these accurately is both a reimbursement opportunity and a patient safety win.

CPT, HCPCS, and ICD-10 Codes for Hepatitis A Vaccine Under CPB 0048

Covered CPT Codes (When Selection Criteria Are Met)

Key ICD-10-CM Diagnosis Codes

The full policy lists 93 ICD-10-CM codes. The table above covers all groups provided in the policy data. Check the full CPB 0048 Aetna system document for the complete list.