Cigna Injectable Fillers Coverage Update

Coverage Criteria & Medical Necessity

Vocal Cord Paralysis - Medically Necessary

Laryngeal injection is considered medically necessary for unilateral vocal cord paralysis when using any of the following:

Medically necessary agents for unilateral vocal cord paralysis: calcium hydroxylapatite (e.g., Radiesse Voice, Prolaryn Plus); autologous fat; bulking agents specifically approved by the U.S. Food and Drug Administration (FDA) for the treatment of unilateral vocal cord paralysis

Includes FDA-cleared laryngeal implants for vocal fold medialization

Velopharyngeal Insufficiency - Medically Necessary

Autologous fat injection is considered medically necessary for the treatment of velopharyngeal insufficiency when ALL of the following are met:

Velopharyngeal insufficiency criteria: History of hypernasal speech; History of nasal regurgitation of food or liquid; Naso-endoscopic evidence of a functional velopharyngeal insufficiency; A speech evaluation, conducted by a speech-language pathologist, which documents the functional impairment that cannot be corrected by speech therapy alone.

All listed criteria must be met

Facial Lipodystrophy Syndrome - Medically Necessary

Injectable fillers approved by the FDA are considered medically necessary for the treatment of photographically documented facial lipodystrophy syndrome caused by antiretroviral therapy in HIV-infected persons when ALL of the following are met:

Facial lipodystrophy criteria: Photographic documentation of facial lipodystrophy syndrome caused by antiretroviral therapy in HIV-infected persons; use of FDA-approved injectable fillers (examples include poly-L-lactic acid [Sculptra] or calcium hydroxylapatite [Radiesse]).

Requires photographic documentation; published trials support durability and QoL improvements

Not Medically Necessary / Cosmetic

Not medically necessary (cosmetic) indications: Injectable fillers including calcium hydroxylapatite, autologous fat, collagen, hyaluronic acid, and poly-L-lactic acid are considered cosmetic and not medically necessary for any indication other than those listed in this policy (examples: body contouring, rhytids/wrinkles, scarring, age‑related volume loss).

Policy states fillers are cosmetic for all other indications

Vocal Cord Paralysis - Medically Necessary (reference)

Considered Medically Necessary when criteria in the applicable policy statements listed above are met:

Vocal Cord Paralysis Coverage: Services such as laryngoscopy with injection (CPT 31513, 31570, 31571, 31573, 31574) and injectable bulking agents or implants (C1878, J3590, L8607, Q2026) are covered when the applicable policy criteria are met.

See policy statements for specific clinical criteria.

Velopharyngeal Insufficiency - Medically Necessary (reference)

Considered Medically Necessary when criteria in the applicable policy statements listed above are met:

VPI Coverage: Autologous soft tissue grafting (CPT 15769, 15773) and posterior pharyngeal wall augmentation are covered when patients meet applicable criteria (e.g., documented functional VPI and appropriate surgical candidacy).

Selection of autologous fat vs alloplastic material should be based on clinical judgment and patient factors.

Facial Lipodystrophy Syndrome (HIV) - Medically Necessary (reference)

Considered Medically Necessary when criteria in the applicable policy statements listed above are met:

LDS Coverage: Dermal filler injections for HIV-associated facial lipoatrophy (HCPCS G0429; Q2026 Radiesse; Q2028 Sculptra) are covered when used to restore facial volume in patients with HIV-associated facial lipoatrophy per the policy criteria.

FDA approvals and clinical trials support use in this indication; documented photographic evidence required.

Not Medically Necessary / Cosmetic (reference)

Cosmetic Indications (reference): Injectable dermal fillers performed solely to alter appearance (e.g., rhytids/wrinkles, scarring, age-related volume loss, body contouring) or to treat psychological/self‑esteem concerns are considered cosmetic and not medically necessary. Certain CPT codes (e.g., 11950–11954, and in some contexts 15773/15774) are listed as not medically necessary for cosmetic indications.

PLLA (Sculptra) use for vocal cord dysfunction is off‑label and considered unproven.

Clinical indications referenced

Policy-level statements and scope were revised (see revision notes); literature supports use of injectable materials for several head and neck conditions.

literature_support: Multiple cited studies and reviews describe injectable therapies (autologous fat, poly‑L‑lactic acid, calcium hydroxylapatite, hyaluronic acid) for vocal fold paralysis, velopharyngeal insufficiency, and HIV-associated facial lipoatrophy, reporting improvements in voice, facial volume restoration, durability, and quality‑of‑life measures.

See cited literature and FDA 510(k)/PMA summaries in the references.

Use of injectable fillers for any indication not addressed in this coverage policy is considered cosmetic and not medically necessary. Refer to other specific policies (e.g., Breast Reconstruction Following Mastectomy or Lumpectomy; Tissue Engineered Skin Substitutes; Gender Dysphoria Treatment; Scar Revision) for coverage criteria applicable to conditions outside the scope of this policy.

Injectable dermal fillers used solely for aesthetic purposes—such as treatment of rhytids (wrinkles), scarring, age-related tissue volume loss, body contouring, or other procedures performed to alter appearance or address psychological/self‑esteem concerns—are considered cosmetic and not medically necessary.

The policy was revised to remove a prior statement that specifically referenced laryngeal injection of hyaluronic acid with or without lidocaine (for example, Restylane); that language is no longer present in the current policy text.

Injectable filler types referenced in the policy as cosmetic or unproven in certain contexts include calcium hydroxylapatite, autologous fat, collagen, hyaluronic acid, and poly-L-lactic acid (PLLA).

Use of PLLA (Sculptra) for vocal cord dysfunction is described in the policy as an off‑label application and is considered unproven for that indication. The policy also notes related coding implications by listing certain CPT codes (for example, CPT 11950–11954 and 1577x codes) in contexts where services are considered not medically necessary.

Within the cited revision notes there is no standalone explicit clause labeled 'Not Medically Necessary' beyond the statements identifying cosmetic indications and removed/added policy statements; the revision summary documents removals and additions rather than introducing a separate NMN clause.

Coding, Billing Codes & Code Tables

FDA product codemixed

MIX	FDA product code dedicated to bulking agents for vocal cord medialization

Example product names referencedmixed

Radiesse	Calcium hydroxylapatite example (brand name)
Prolaryn	Calcium hydroxylapatite laryngeal implant (brand name)
Sculptra	Poly-L-lactic acid example (brand name)

Covered CPT Codes (Vocal Cord Paralysis)CPTCovered

15773	Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate
31513	Laryngoscopy, indirect; with vocal cord injection
31570	Laryngoscopy, direct, with injection into vocal cord(s), therapeutic
31571	Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or telescope
31573	Laryngoscopy, flexible; with therapeutic injection(s) (eg, chemodenervation agent or corticosteroid, injected percutaneous, transoral, or via endoscope channel), unilateral
31574	Laryngoscopy, flexible; with injection(s) for augmentation (eg, percutaneous, transoral), unilateral

Covered Implant/Biologic/HCPCS/J-codes (Vocal Cord Medialization)HCPCS | J-codeCovered

C1878	Material for vocal cord medialization, synthetic (implantable)
J3590	Unclassified biologics
L8607	Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies
Q2026	Injection, Radiesse, 0.1 ml

Covered CPT Codes (Velopharyngeal Insufficiency)CPTCovered

15769	Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)
15773	Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate

Covered HCPCS Codes (Facial Lipodystrophy Syndrome)HCPCSCovered

G0429	Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy)
Q2026	Injection, Radiesse, 0.1 ml
Q2028	Injection, Sculptra, 0.5 mg

Considered Not Medically Necessary CodesCPTNot Covered

11950	Subcutaneous injection of filling material (eg, collagen); 1 cc or less
11951	Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc
11952	Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc
11954	Subcutaneous injection of filling material (eg, collagen); over 10.0 cc
15773	Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate
15774	Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof

FDA 510(k)/PMA summaries referencedmixed

K060815	510(k) summary - Juliesse Injectable Laryngeal Implant
K033398	510(k) summary - Laryngeal Augmentation Implant
K070090	510(k) summary - Radiesse laryngeal implant
P800022	PMA - CosmoDerm/CosmoPlast supplement
N18286	PMA - Gelfoam Sterile Powder
P030032	PMA - Hylaform (Hylan B gel)
P050047	PMA - Juvederm
P050037	PMA - Radiesse 1.3cc and 0.3cc
P020023	PMA - Restylane (archived)
P030050	PMA - Sculptra and Sculptra Aesthetic

Injectate volume threshold for CPT 15773

Injectate volume threshold (CPT 15773)25 cc or less

CPT descriptorGrafting of autologous fat harvested by liposuction technique to face...; 25 cc or less injectate

Related coverage noteCPT 15773 used in vocal cord paralysis and velopharyngeal insufficiency contexts per policy criteria

Provider Actions, Authorization & Documentation

Prior Authorization

Plan-dependent prior authorization and coverage

Coverage and prior authorization requirements vary by Cigna plan. Refer to the member's specific benefit plan document (Evidence of Coverage, Summary Plan Description, Group Service Agreement, or similar) to confirm coverage, prior authorization, and any plan-specific limitations prior to rendering services.

Confirm member-specific coverage and prior authorization rules before scheduling or performing services.

Prior Authorization

Prior authorization for injectable/implant procedures

Prior authorization is required for certain injectable and implantable laryngeal procedures and associated codes when the service is subject to the plan's prior authorization process. Verify prior authorization requirements with the member's plan prior to submission.

Background & Evidence Summary

Injectable soft tissue fillers are substances used to restore tissue volume loss from aging, lipoatrophy, injury, or surgery. Products vary by longevity (resorbable versus longer‑lasting or permanent) and include agents such as calcium hydroxylapatite, collagen, hyaluronic acid, poly-L-lactic acid, polymethylmethacrylate, hydrogel polymers, silicone, and autologous fat. These materials are used medically to correct anatomic defects or functional problems (for example, to medialize or augment vocal folds, treat velopharyngeal insufficiency, or restore facial volume in HIV‑associated facial lipoatrophy); product durability and specific indications vary by agent and by regulatory approvals.

Definitions & Terminology

Injectable fillers — definition & examples

DefinitionInjectable dermal or soft tissue fillers are substances used to restore tissue volume loss due to aging, lipoatrophy, injury, or trauma.

Examples — resorbableHyaluronic acid, collagen, calcium hydroxylapatite, poly-L-lactic acid

Examples — permanent or long-lastingPolymethylmethacrylate microspheres, hydrogel polymers, silicone

Autologous optionAutologous fat (used as a filler for volume restoration)

Glottis insufficiency / vocal cord paralysis

DefinitionGlottis insufficiency is phonatory compromise due to vocal cord paralysis, atrophy, or scarring resulting in voice changes and possible airway/swallowing problems.

Revision History & Policy Changes

2025-09-15annual_reviewLatest

Title change; removed policy statement for laryngeal injection of hyaluronic acid (e.g., Restylane); added policy statement for velopharyngeal insufficiency.

2024-05-15annual_revision

Annual revision noted with no changes to coverage.

OpenPayer

Injectable Fillers for Head and Neck Conditions

Coverage Criteria & Medical Necessity

Coding, Billing Codes & Code Tables

Provider Actions, Authorization & Documentation

Background & Evidence Summary

Definitions & Terminology

Revision History & Policy Changes