Varicella and Herpes Zoster Vaccines — CPB 0115 | AETNA Coverage Update

TL;DR: Aetna modified CPB 0115 covering varicella and herpes zoster vaccines, effective September 26, 2025. Here's what billing teams need to do.

This update to the Aetna varicella and herpes zoster vaccines coverage policy clarifies medical necessity criteria across CPT codes 90716, 90710, 90750, and 90736. The policy governs who qualifies for Shingrix (CPT 90750), MMRV (CPT 90710), and varicella vaccine (CPT 90716) under Aetna plans — and it draws a hard line on what Aetna will not pay for. If your practice bills immunizations or manages a patient population that includes immunocompromised adults, HSCT recipients, or oncology patients, this affects your reimbursement.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna
Policy	Varicella and Herpes Zoster Vaccines
Policy Code	CPB 0115 Aetna
Change Type	Modified
Effective Date	September 26, 2025
Impact Level	Medium
Specialties Affected	Primary care, infectious disease, oncology, hematology, immunology, transplant medicine
Key Action	Audit charge capture for CPT 90750 and 90736 before billing Aetna claims post-September 26, 2025

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Aetna Varicella and Herpes Zoster Vaccine Coverage Criteria and Medical Necessity Requirements 2025

The Aetna varicella and herpes zoster vaccines coverage policy covers five distinct scenarios. Each one has specific eligibility criteria. Billing the wrong indication — or missing a required criterion — is the fastest path to a claim denial.

Varicella (CPT 90716): Aetna covers the varicella vaccine as a preventive service when it follows CDC Advisory Committee on Immunization Practices (ACIP) recommendations. No special criteria beyond ACIP alignment. This is your routine pediatric chickenpox vaccination — straightforward to bill when the indication is ICD-10 B01.9.

MMRV Combination Vaccine (CPT 90710): Aetna covers ProQuad as a preventive alternative to separate MMR (CPT 90707) and varicella (CPT 90716) vaccines. The child must be between 12 months and 12 years of age. Simultaneous administration of MMR and varicella must be indicated. If the patient doesn't meet all three conditions — age range, preventive intent, and simultaneous indication — bill separately instead.

Varicella in HIV-Positive Patients (CPT 90716): This is where it gets specific. Aetna considers varicella vaccination medically necessary for HIV-infected patients, but the criteria split by age. For patients over eight years old, the patient must be varicella zoster virus (VZV) negative and have a CD4 count above 200 cells/µL. For HIV-infected children aged one to eight years, the CD4 percentage must exceed 15%. Document these lab values before you bill. ICD-10 code B20 applies here, and your documentation needs to support the immunologic threshold.

Shingrix — Recombinant Herpes Zoster Vaccine (CPT 90750): This is the section with the most billing complexity. Aetna covers Shingrix as a two-dose series under three separate indications:

#	Covered Indication Copy
1	Adults 50 years and older — for prevention of herpes zoster (shingles), regardless of prior Zostavax history
2	Adults 50 and older who previously received Zostavax (CPT 90736) — Shingrix is covered as a follow-up series
3	Adults 18 and older who are immunodeficient or immunosuppressed — this group has a much lower age threshold and covers a wide range of conditions

That third indication is clinically broad. Aetna explicitly includes autologous hematopoietic stem cell transplant (HSCT) recipients, hematologic malignancy patients, solid organ transplant recipients, solid tumor patients on chemotherapy, HIV-infected adults, patients with primary immunodeficiencies, patients with autoimmune and inflammatory conditions, and patients on immunosuppressive medications or therapies.

If your practice bills herpes zoster vaccine claims for oncology or transplant patients under age 50, this third bucket is where you establish medical necessity. The ICD-10 codes for supporting diagnoses span the C-codes (solid tumors, hematologic malignancies), B20 (HIV), and condition-specific codes like cystic fibrosis (E84.x), diabetes mellitus (E08–E13), Parkinson's disease (G20.x), and Alzheimer's disease (G30.x), among others.

Re-vaccination After HSCT (CPT 90750): Aetna covers a Shingrix re-vaccination series for HSCT recipients. Three conditions must all be met: at least 24 months must have passed since the transplant, the recipient must not have current graft-versus-host disease (check for active D89.810–D89.813 diagnoses), and the member must be considered immunocompetent at the time of vaccination. All three must be affirmative. A current GVHD code on the claim will complicate reimbursement. Work with your transplant team to establish a documentation checklist.

This is not a policy where prior authorization requirements are explicitly called out in the CPB language, but that doesn't mean your specific plan won't require it. Check plan-level benefits before assuming preventive vaccine billing flows through without a prior auth step.

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Aetna Herpes Zoster Vaccine Exclusions and Non-Covered Indications

Aetna draws two clear lines here.

Zostavax is not covered. CPT 90736 — the live zoster vaccine — is listed as not covered for indications in CPB 0115. If you have older charge masters or billing templates still referencing 90736 as a billable code, remove it now. Billing 90736 to Aetna is a denial waiting to happen.

Shingrix boosters beyond the primary two-dose series are experimental. Aetna is explicit: any repeat or booster dose of Shingrix beyond the initial two-dose primary series is considered experimental, investigational, or unproven. This applies universally — not just for certain patient populations. There is no exception in the current policy for high-risk patients who might clinically benefit from an additional dose.

The real issue here is that some clinicians, especially in oncology and transplant settings, may recommend a third dose for patients who mounted a poor immune response. If that clinical scenario comes up in your practice, the coverage denial will be automatic under this policy. Document the clinical rationale, but don't expect reimbursement from Aetna without an appeal — and even then, the "experimental/investigational" designation is a hard wall.

If your practice sees this pattern frequently, loop in your compliance officer and billing consultant before the September 26, 2025 effective date to set expectations with your clinical team.

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Coverage Indications at a Glance

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Aetna Varicella and Herpes Zoster Vaccine Billing Guidelines and Action Items 2025

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Varicella and Herpes Zoster Vaccines Under CPB 0115

Covered CPT Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
90710	CPT	Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use
90716	CPT	Varicella virus vaccine (VAR), live, for subcutaneous use
90750	CPT	Zoster (shingles) vaccine (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection [Shingrix]

Not Covered / Experimental Codes

Code	Type	Description	Reason Copy
90736	CPT	Zoster (shingles) vaccine (HZV), live, for subcutaneous injection [Zostavax]	Not covered for indications listed in CPB 0115

Key ICD-10-CM Diagnosis Codes

Note: CPB 0115 references 106 ICD-10-CM codes in total. The table above shows a subset drawn from the available policy data — it is not complete. Confirm the full code set against the source policy at app.payerpolicy.org/p/aetna/0115 before finalizing your billing guidelines.

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