Does Z20.89 require prior authorization?

No, Z20.89 does not require prior authorization (high confidence). Covered without prior authorization.

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`Z20.89`, Contact with and (suspected) exposure to other communicable diseases

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

For OPV use, document parental/caregiver refusal of IPV and that the risk of vaccine-associated paralytic polio (VAPP) was discussed prior to OPV administration.
Document clinical indication for adult vaccination when at increased risk (e.g., occupation: health-care worker or laboratory worker; membership in population group during an outbreak; travel to endemic/epidemic area; known exposure risk).
Document that live OPV was not administered to contraindicated patients (e.g., hematopoietic stem cell transplant recipients, patients with immunodeficiency) and any relevant contraindications.
Record vaccine product, CPT code (as applicable: 90698, 90713, 90723), ICD-10 code (Z20.89 or Z23 when applicable), administration route, and dates of previous doses to verify intervals and series completion.

Key Coverage Criteria

Aetna considers polio vaccine a medically necessary preventive service for members according to the recommendations of the Centers for Disease Control and Prevention's (CDC) Advisory Committee for Immunization Practices (ACIP).
Routine childhood immunization with injectable inactivated poliovirus vaccine (IPV) using the ACIP-recommended schedule: 4 doses at ages 2 months, 4 months, 6 to 18 months, and 4 to 6 years.
Use of oral polio vaccine (OPV) only for the following special circumstances: children of parents who are not willing to have their child receive the recommended injectable form (OPV may be given only for the 3rd or 4th dose or both after discussing the risk of VAPP with parents/caregivers); mass vaccination campaigns to control outbreaks of paralytic polio; unvaccinated children who will be traveling in less than 4 weeks to areas where polio is endemic.
Polio vaccine for adults (>18 years) who are at increased risk of exposure to poliovirus, including: health-care workers in close contact with individuals who may be excreting wild polioviruses; individuals who are members of specific population groups during an outbreak of polio caused by wild polioviruses; laboratory workers handling specimens which may contain polioviruses; travelers to areas where poliomyelitis is endemic or epidemic.
For adults at increased risk of exposure: primary immunization with IPV is recommended with a schedule of 2 doses given at 1 to 2 month intervals, and a 3rd dose given 6 to 12 months later.
CPT codes covered if selection criteria are met: 90698 (DTaP-IPV/Hib), 90713 (Poliovirus vaccine, inactivated (IPV)), 90723 (DTaP-HepB-IPV).

3 Active Policies

AETNA-CPB-0402, Polio Vaccine

AETNA-CPB-0644, Orthopoxvirus Vaccines

AETNA-CPB-0650, Polymerase Chain Reaction Testing: Selected Indications

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Z20.89, Contact with and (suspected) exposure to other communicable diseases