CurrentColorado Rocky Mountain Health PlansPolicy CS371.C

Injectable Dermal Fillers and Bulking Agents

Coverage and medical necessity guidance for dermal filler injections (including HIV-associated facial lipoatrophy) and injectable bulking agents for vocal fold medialization; applies to Colorado Rocky Mountain Health Plans membership except where state-specific exceptions noted.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyInjectable Dermal Fillers and Bulking Agents

Policy CodePolicy CS371.C

Change TypeCodes and content updated

Effective DateJanuary 1, 2026

Next Review Date

Key ActionProvide medical records documentation to demonstrate the member meets clinical criteria for coverage when requesting authorization.

SourceLink

POLICY UPDATE CHANGES

Removed content/language pertaining to the state of Louisiana.

Added CPT codes 31570, 31571, and 31574.

Updated Description of Services section to reflect the most current information.

Approximately 50%HIV patients on HAART estimated to develop significant facial lipoatrophy

CS371.CPolicy identifier

31570, 31571, 31574Added CPT codes for laryngoscopy with injection

Radiesse, SculptraReconstructive fillers for HIV facial lipoatrophy

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Coverage Criteria

HIV-associated Facial Lipoatrophy

Covered when ALL of the following are met for facial lipoatrophy in people with HIV:

HIV facial lipoatrophy - reconstructive coverage: Radiesse and Sculptra are considered reconstructive and medically necessary for the treatment of facial defects due to facial lipoatrophy in individuals living with human immunodeficiency virus (HIV) infection.

Vocal Fold Insufficiency / Dysfunction

Covered when ALL of the following are met for vocal fold insufficiency:

Vocal fold insufficiency - bulking agents: Injectable bulking agents are proven and medically necessary for the treatment of vocal fold insufficiency/dysfunction when used according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions.

Use must follow FDA labeling.

Cosmetic Use - Not Medically Necessary

Not covered for other indications:

Other indications for dermal fillers: Radiesse and Sculptra are considered cosmetic and not medically necessary for all other indications. The use of all other dermal filler products is considered cosmetic and not medically necessary.

All dermal filler products other than Radiesse and Sculptra are considered cosmetic and not medically necessary. Radiesse (calcium hydroxylapatite) and Sculptra (poly-L-lactic acid) are identified in this policy as reconstructive and medically necessary only for treatment of facial lipoatrophy in individuals living with HIV; outside of that indication these and all other fillers are considered cosmetic.

The use of dermal fillers for indications other than HIV-associated facial lipoatrophy is not medically necessary. Specifically, this policy considers the use of any dermal filler products — except for Radiesse and Sculptra when used for HIV facial lipoatrophy — to be cosmetic and therefore excluded from coverage.

Coding

CPT codes for laryngoscopy with injectionCPT

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.
31574	Laryngoscopy, flexible; with injection(s) for augmentation (e.g., percutaneous, transoral), unilateral

HCPCS G-codeHCPCS

G0429

Dermal Filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy).

Durable Medical Equipment / Implantable supplyHCPCS

L8607

Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies.

Q-codes for specific fillersHCPCS

Q2026	Injection, Radiesse, 0.1ml
Q2028	Injection, sculptra, 0.5 mg

Provider Actions & Billing Guidance

Note

Applicable Codes

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.

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
31574 — Laryngoscopy, flexible; with injection(s) for augmentation (e.g., percutaneous, transoral), unilateral
G0429 — Dermal Filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS)
L8607 — Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies
Q2026 — Injection, Radiesse, 0.1 ml
Q2028 — Injection, Sculptra, 0.5 mg

Background

Facial lipoatrophy related to antiretroviral therapy in people living with HIV can produce visible facial defects that have meaningful effects on appearance and quality of life. The policy recognizes that two injectable agents, Radiesse and Sculptra, are considered reconstructive and medically necessary when used specifically to treat facial lipoatrophy in this population; other dermal fillers are regarded as cosmetic and not medically necessary.

Definitions

Vocal fold insufficiency — condition definition, symptoms and risks

DefinitionCondition in which one or both vocal cords do not close correctly (glottic insufficiency) leading to vocal fatigue, poor voice quality or tone, and difficulty speaking, swallowing, or coughing.

Common symptomsVocal fatigue, poor voice quality/tone, difficulty speaking, difficulty swallowing, and impaired cough reflex.

Risks/complicationsIncreased risk of laryngeal penetration, aspiration, and pneumonia if glottic closure is inadequate.

Synonyms/related termsVocal cord insufficiency, vocal cord dysfunction, paradoxical vocal fold movement, glottal insufficiency.

Radiesse / Sculptra — definitions and role as FDA-approved injectable fillers for HIV facial lipoatrophy

Radiesse (calcium hydroxylapatite)

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyInjectable Dermal Fillers and Bulking Agents

Policy CodePolicy CS371.C

Change TypeCodes and content updated

Effective DateJanuary 1, 2026

Next Review Date

Key ActionProvide medical records documentation to demonstrate the member meets clinical criteria for coverage when requesting authorization.

SourceLink

On This Page

Documentation Required

Medical Records Documentation May Be Required

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the services requested; refer to the guidelines titled Medical Records Documentation Used for Reviews. Lack of required medical records documentation may result in denial of coverage.

Health records (progress notes, operative reports, laryngoscopy findings) may be requested
Failure to supply requested documentation can cause claim or authorization denial

Note

Clinical Guidance: Voice Therapy and Treatment Options

Clinical management often includes voice therapy and consideration of non-surgical options prior to or in conjunction with injection medialization for vocal fold insufficiency. AAO-HNS guidance recommends counseling patients on rehabilitation options and recognizes injection medialization as a temporary intervention that may reduce need for later surgical reconstruction.

Consider voice therapy / speech-language pathology referral
Discuss nonsurgical alternatives and temporary nature of injections with the patient

FDA-approved injectable filler for restoration/correction of facial lipoatrophy in people with HIV (approved Dec 22, 2006). Considered reconstructive and medically necessary for HIV-associated facial lipoatrophy; cosmetic for other indications.

Sculptra (poly-L-lactic acid)FDA-approved injectable filler to correct facial fat loss in people with HIV (approved Aug 3, 2004). Considered reconstructive and medically necessary for HIV-associated facial lipoatrophy; cosmetic for other indications.

RoleBoth agents are FDA-approved and indicated for treatment of facial lipoatrophy in individuals living with HIV; injectable fillers improve appearance and quality of life in this population.