Pneumococcal Vaccines (CPB 0037, reviewed 2026-03-02)

By March 2, 2026: Billing team must update claims processing rules and billing software to enforce new pneumococcal vaccine coverage criteria. Specifically: (1) Configure system to require PCV15, PCV20, or PCV21 for covered age/risk groups; (2) Implement logic to deny claims for CPT 87652 (Streptococcus group A quantification) as it is not covered under this policy; (3) Add clinical decision support to verify vaccine sequencing rules (e.g., if PCV20/PCV21 administered, PPSV23 is not medically necessary; if PCV15 administered, require PPSV23 follow-up timing); (4) Update prior authorization templates to reference risk conditions listed in Footnotes 1 and 2; (5) Train billing and authorization staff on age-based eligibility (infants 2-59 months, children 6-18 with risk conditions, adults 19-49 with risk conditions, all adults 50+); (6) Verify CPT 90460, 90461, 90471, 90472 administration codes are correctly paired with vaccine codes 90671, 90677, 90684, 90732. Failure to implement these changes will result in claim denials for non-compliant vaccine sequencing and coverage denials for ineligible populations.