Aetna modified CPB 1027 covering RSV vaccines for adults and pregnant members, effective November 8, 2025. Here's what billing teams need to know.
Aetna, a CVS Health company updated its RSV vaccine coverage policy under CPB 1027 Aetna system to reflect current CDC ACIP recommendations. The change directly affects billing for CPT 90678 (Abrysvo/Pfizer), CPT 90679 (Arexvy/GSK), and CPT 90683 (mRESVIA/Moderna) across three distinct eligible populations. If your practice vaccinates adults over 50 or counsels pregnant patients on RSV protection, this policy governs whether your claims pay or deny.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Respiratory Syncytial Virus (RSV) Vaccines for Adult and Maternal Use |
| Policy Code | CPB 1027 |
| Change Type | Modified |
| Effective Date | November 8, 2025 |
| Impact Level | High |
| Specialties Affected | Internal medicine, family medicine, OB/GYN, infectious disease, preventive care, pharmacy-based immunization |
| Key Action | Confirm patient age, gestational age, or risk-factor documentation before billing CPT 90678, 90679, or 90683 — claims without supporting diagnosis codes will deny |
Aetna RSV Vaccine Coverage Criteria and Medical Necessity Requirements 2025
The Aetna RSV vaccine coverage policy ties medical necessity directly to CDC ACIP guidance. There are three covered populations. Know which bucket your patient falls into before you bill.
Population 1: Age 75 and older. Arexvy (CPT 90679), Abrysvo (CPT 90678), or mRESVIA (CPT 90683) are covered with no additional risk-factor documentation required. Age alone satisfies medical necessity. Bill Z29.11 as the primary diagnosis code.
Population 2: Ages 50 to 74 with increased risk. Coverage applies, but the patient must have at least one documented risk factor for severe RSV disease. The policy references an appendix listing qualifying conditions. Without that documentation in the chart, your claim will deny. Bill Z29.11 and add the relevant comorbidity ICD-10 code.
Population 3: Pregnant members, Abrysvo only. Aetna covers a single dose of Abrysvo (CPT 90678) — not Arexvy, not mRESVIA — for pregnant members at 32 through 36 weeks gestational age. The vaccine protects infants from birth through six months. Bill Z29.11 plus the gestational age code (Z3A.32 through Z3A.36) that matches the week of administration.
Timing matters under this Aetna RSV vaccine coverage policy. Seasonal administration runs September through January in most of the continental U.S. Alaska and tropical-climate jurisdictions follow state or territorial guidance. Claims submitted outside the seasonal window may face scrutiny — document the clinical rationale if you administer outside that range.
The policy does not explicitly list prior authorization requirements in the published bulletin. That said, prior auth requirements vary by plan and product. Check the patient's specific benefit plan before administering, especially for members in the 50–74 age band where risk-factor documentation creates an inherent coverage question.
Reimbursement flows under the vaccine CPT codes (90678, 90679, 90683) plus the appropriate administration code. Use CPT 90471 for the first vaccine administered at the encounter. If a second vaccine is given at the same visit, add CPT 90472.
Aetna RSV Vaccine Exclusions and Non-Covered Indications
Aetna is explicit about what it will not cover. Three categories are considered experimental, investigational, or unproven.
Members under 60 who don't meet the criteria in Section I. If a patient is 50–59 without documented risk factors, the vaccine is not covered. Don't assume age alone carries the claim in this band.
Pregnant members outside the 32–36 week window. Administration before 32 weeks or after 36 weeks gestational age is not covered. This is a narrow window — bill the gestational age ICD-10 codes (Z3A.32 through Z3A.36) precisely. A Z3A.31 or Z3A.37 on the claim will trigger a claim denial.
Revaccination. This is a one-time, single-dose vaccine under the current policy. A second dose for the same member — regardless of how much time has passed — is not covered. If your EHR doesn't flag prior RSV vaccination history, build a manual check into your workflow before administering.
The non-coverage of revaccination is the area with the highest financial exposure. An accidental second-dose administration with no recourse for reimbursement is a hard cost. Flag RSV vaccination history as a required pre-visit check in your clinical workflow.
Coverage Indications at a Glance
| Indication | Status | Vaccine Options | Key Codes |
|---|---|---|---|
| Adults 75+ | Covered | Arexvy, Abrysvo, mRESVIA | CPT 90678, 90679, 90683; ICD-10 Z29.11 |
| Adults 50–74 with increased risk of severe RSV | Covered (with risk documentation) | Arexvy, Abrysvo, mRESVIA | CPT 90678, 90679, 90683; ICD-10 Z29.11 + comorbidity code |
| Pregnant members, 32–36 weeks gestational age | Covered | Abrysvo only | CPT 90678; ICD-10 Z29.11, Z3A.32–Z3A.36 |
| Adults under 60 without qualifying risk factors | Not Covered / Experimental | N/A | N/A |
| Pregnant members under 32 weeks | Not Covered / Experimental | N/A | N/A |
| Pregnant members over 36 weeks | Not Covered / Experimental | N/A | N/A |
| Revaccination (any population) | Not Covered / Experimental | N/A | N/A |
| Administration outside September–January (continental U.S.) | Requires clinical documentation | Per indication | Document seasonal rationale |
Aetna RSV Vaccine Billing Guidelines and Action Items 2025
| # | Action Item |
|---|---|
| 1 | Update charge capture for CPT 90678, 90679, and 90683 before your next RSV vaccine clinic. The effective date is November 8, 2025. Every claim submitted after that date must align with CPB 1027's updated criteria or you're billing on an outdated framework. |
| 2 | Build age and gestational age checkpoints into your pre-visit workflow. For adults, confirm the patient is 75+ or has documented risk factors if ages 50–74. For pregnant patients, confirm gestational age falls between 32 and 36 weeks before Abrysvo is ordered. A workflow miss here is a denied claim and a potential write-off. |
| 3 | Pair every RSV vaccine claim with Z29.11 plus a supporting diagnosis code. Z29.11 alone isn't enough for the 50–74 risk-based population. The comorbidity that qualifies the patient for coverage needs to appear on the claim. For maternal vaccination, add the exact gestational age code — Z3A.32 for 32 weeks, Z3A.33 for 33 weeks, Z3A.34 for 34 weeks, Z3A.35 for 35 weeks, or Z3A.36 for 36 weeks. |
| 4 | Flag RSV vaccination history as a required field in your intake process. Revaccination is not covered. If your EHR doesn't surface prior RSV vaccine records automatically, add a manual verification step. Administering a second dose without coverage recourse is a direct loss. |
| 5 | Confirm Abrysvo-only restriction for maternal RSV vaccine billing. Only CPT 90678 is covered for pregnant patients. Arexvy (CPT 90679) and mRESVIA (CPT 90683) are not covered for this indication. If your practice stocks multiple RSV vaccine products, make sure clinical staff know which product is billable for which population. |
| 6 | Check for overlap with nirsevimab (Beyfortus) in newborn cases. Aetna's policy notes that most infants need either maternal RSV vaccination or infant nirsevimab — not both. If a mother received Abrysvo before delivery and the newborn is later considered for nirsevimab, flag it. Infant RSV immunization billing falls under CPB 1038, and duplicate-protection claims will get scrutinized. |
| 7 | Verify prior authorization requirements at the plan level. CPB 1027 doesn't mandate prior auth across the board, but individual Aetna plan products may have their own requirements — especially for commercial fully-insured versus ASO plans. If you're not sure how prior authorization applies to your patient mix, contact Aetna provider services or loop in your billing consultant before administering. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for RSV Vaccines Under CPB 1027
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 90678 | CPT | Respiratory syncytial virus vaccine, preF, subunit, bivalent, for intramuscular use (Abrysvo/Pfizer) |
| 90679 | CPT | Respiratory syncytial virus vaccine, preF, recombinant, subunit, adjuvanted, for intramuscular use (Arexvy/GSK) |
| 90683 | CPT | Respiratory syncytial virus vaccine, mRNA lipid nanoparticles, for intramuscular use (mRESVIA/Moderna) |
| 90382 | CPT | Respiratory syncytial virus, monoclonal antibody, seasonal dose, 0.7 mL, for intramuscular use |
Related Administration CPT Codes
| Code | Type | Description |
|---|---|---|
| 90471 | CPT | Immunization administration — first vaccine (includes intramuscular injection) |
| 90472 | CPT | Immunization administration — each additional vaccine (list separately in addition to primary code) |
| 96372 | CPT | Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular |
| 96380 | CPT | Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection |
| 96381 | CPT | Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection (additional code) |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| Z29.11 | Encounter for prophylactic immunotherapy for respiratory syncytial virus (RSV) — use for all covered RSV vaccine encounters |
| Z3A.32 | 32 weeks gestation of pregnancy |
| Z3A.33 | 33 weeks gestation of pregnancy |
| Z3A.34 | 34 weeks gestation of pregnancy |
| Z3A.35 | 35 weeks gestation of pregnancy |
| Z3A.36 | 36 weeks gestation of pregnancy |
| B97.4 | Respiratory syncytial virus as the cause of disease classified elsewhere |
| J12.1 | Respiratory syncytial virus pneumonia |
| J20.5 | Acute bronchitis due to respiratory syncytial virus |
| J21.5 | Acute bronchiolitis due to respiratory syncytial virus |
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