Wiki Prevnar PCV20 Aetna Denials for Pediatrics

[afairfield@altavistamh.com]

Hello,
Has anyone else gotten denials from Aetna regarding the administration of Prevnar 20 to 2, 4, and 6 month olds? According to the ACA, insurance companies have a year before they have to recognize and pay for new vaccines. We can no longer order Prevnar 13 so we have to give Prevnar 20. However, Aetna has denied all claims sent with CPT 90677. I am going to appeal these claims with the ACIP recommendations but I am wondering if anyone has gotten paid for these vaccines for patients under the age of 19 years old?

 

[wlf78911]

I feel you, I am in CA and my office use Prevnar 15 CPT 90671 and some health plan denied as not in Medi-Cal schedule, I've learned that it takes a while for Med-Cal system to update any of the new codes for those health plan to follow

 

[afairfield@altavistamh.com]

That's frustrating! Is your practice still giving the Prevnar or is the patient referred out?
According to the ACA, payors have 12 months after the new plan year following ACIP recommendation to recognize and pay for new vaccines.

 

[wlf78911]

That's frustrating! Is your practice still giving the Prevnar or is the patient referred out?
According to the ACA, payors have 12 months after the new plan year following ACIP recommendation to recognize and pay for new vaccines.

I do know where we can refer them out to be honest.

 

[cnjacobs15]

We just received our first denial from Aetna for a pediatric patient received 90677.. I appealed that but have not received a decision yet. and in the meantime my supervisor was going to send the information to our Aetna Provider rep to see if they had any Recommendations. our big issue is with UHC denying 90677 for the pediatric patients denying 90677 as being inconsistent with the patient's age. UHC even updated and added it to their Preventive Care Services: Vaccine Codes policy. which we attach that to our claim reconsideration and they uphold their decision on the denial. I swear vaccines will be the death of me! between this issue and the new RSV/Covid...

 

[BillingAdvocate]

Aetna just reviewed and updated their medical policy on 10/24. They now consider Prevnar 20 medically necessary in children. Hopefully they update their claims processing system to reflect that!

 

[cnjacobs15]

Aetna just reviewed and updated their medical policy on 10/24. They now consider Prevnar 20 medically necessary in children. Hopefully they update their claims processing system to reflect that!

oh thank you so much for that!!!