`90758` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 90758

Payer coverage policies that name 90758

90758 appears in 2 coverage policies from Aetna, Blue Cross & Blue Shield of Rhode Island.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Vaccines for Travel (0473)	covered if criteria are met	Jul 24, 2026	payer document
Blue Cross & Blue Shield of Rhode Island	Immunizations Adult and Pediatric MEDICAL COVERAGE POLICY \| 8	covered if criteria are met	Jun 9, 2026	payer document

Medicaid fee-for-service

Prior authorization required or conditional in IN.

KY: $0.00 (physician, non-facility), effective Jan 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

90758 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 90758

Payer coverage policies that name 90758

Medicaid fee-for-service

`90758` CPT® code: payer coverage and prior authorization