ModifiedColorado Rocky Mountain Health PlansPolicy CS371NJ.D

Injectable Dermal Fillers and Bulking Agents (for New Jersey Only)

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Coverage of injectable dermal fillers for HIV-associated facial lipoatrophy and injectable bulking agents for vocal fold insufficiency or dysfunction; applies only to New Jersey members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyInjectable Dermal Fillers and Bulking Agents (for New Jersey Only)

Policy CodePolicy CS371NJ.D

Change TypeModified

Effective DateNovember 1, 2026

Next Review DateNot specified

Key ActionEnsure the medical record fully supports medical necessity and includes relevant history, examination, and pertinent diagnostic results.

SourceLink

POLICY UPDATE CHANGES

CPT codes 31570, 31571, and 31574 were removed from the applicable codes.

The Description of Services, Clinical Evidence, FDA, and References sections were updated to reflect current information.

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ModifiedColorado Rocky Mountain Health PlansPolicy CS371NJ.D

Injectable Dermal Fillers and Bulking Agents (for New Jersey Only)

Customize your policy alerts

Sign up for Colorado Rocky Mountain Health Plans Policy CS371NJ.D alerts

Get alerted when Policy CS371NJ.D changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage of injectable dermal fillers for HIV-associated facial lipoatrophy and injectable bulking agents for vocal fold insufficiency or dysfunction; applies only to New Jersey members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyInjectable Dermal Fillers and Bulking Agents (for New Jersey Only)

Policy CodePolicy CS371NJ.D

Change TypeModified

Effective DateNovember 1, 2026

Next Review DateNot specified

Key ActionEnsure the medical record fully supports medical necessity and includes relevant history, examination, and pertinent diagnostic results.

SourceLink

POLICY UPDATE CHANGES

CPT codes 31570, 31571, and 31574 were removed from the applicable codes.

The Description of Services, Clinical Evidence, FDA, and References sections were updated to reflect current information.

Covered Services and Medical Necessity Criteria

Dermal filler injections for HIV-associated facial lipoatrophy

Covered as reconstructive and medically necessary when all of the following are met:

Eligible product and indication

Eligible product
- The requested dermal filler product is Radiesse.
- The requested dermal filler product is Sculptra.
Covered condition
- Treatment is for facial defects due to facial lipoatrophy.
- The individual is living with human immunodeficiency virus (HIV) infection.

Injectable bulking agents for vocal fold insufficiency

Covered when all of the following are met:

Covered indication and appropriate use

Covered condition
- Treatment is for vocal fold insufficiency or dysfunction.
FDA-labeled use
- The injectable bulking agent is used according to U.S. Food and Drug Administration (FDA)-labeled indications, contraindications, warnings, and precautions.

Radiesse and Sculptra are considered cosmetic and not medically necessary for indications other than treatment of facial defects due to facial lipoatrophy in individuals living with HIV infection. All other dermal filler products are also considered cosmetic and not medically necessary.

Dermal filler injections are not medically necessary for indications other than HIV-associated facial lipoatrophy. This includes use of Radiesse, Sculptra, or any other dermal filler product for cosmetic or other non-covered indications.

Applicable and Removed Codes

Applicable HCPCS CodesHCPCS

G0429	Dermal Filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy).
L8607	Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies.
Q2026	Injection, Radiesse, 0.1ml.
Q2028	Injection, Sculptra, 0.5 mg.

Applicable Codes RemovedCPTNot Covered

31570	Removed applicable CPT code
31571	Removed applicable CPT code
31574	Removed applicable CPT code

Documentation, Billing, and Use Requirements

Documentation Required

Medical Necessity Documentation Required

The patient's medical record must fully support the medical necessity of the requested services. Documentation may be required for review but does not guarantee coverage and must be legible, maintained in the medical record, and made available upon request.

Include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, as applicable.

Denial Risk

Non-Covered Cosmetic Dermal Filler Use

Dermal fillers are considered cosmetic and not medically necessary when used for indications other than facial defects due to facial lipoatrophy in individuals living with HIV infection.

Radiesse and Sculptra are covered as reconstructive and medically necessary only for facial defects due to facial lipoatrophy in individuals with HIV infection.

Clinical Background

HIV-associated facial lipoatrophy is facial fat loss that may result from HIV infection or antiretroviral therapy. It can substantially affect a person’s appearance and quality of life and may influence treatment adherence. Radiesse and Sculptra are FDA-approved fillers for correcting facial fat loss in people with HIV and are considered reconstructive and medically necessary for facial defects related to this condition.

Terminology

Vocal Cord Insufficiency

ConditionVocal cord insufficiency, also known as vocal cord dysfunction, paradoxical vocal fold movement, or glottal insufficiency, occurs when one or both vocal cords do not open correctly.

Effect on closureWhen the glottis does not close properly, vocal function can be impaired.

Voice effectsPossible effects include vocal fatigue and poor voice quality or tone.

Other effectsThe condition may cause difficulty speaking, swallowing, or coughing and increases the risk of larynx penetration, aspiration, and pneumonia.

Vocal Fold Injection

ProcedureVocal fold injection involves injecting a bulking agent into the affected vocal fold.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyInjectable Dermal Fillers and Bulking Agents (for New Jersey Only)

Policy CodePolicy CS371NJ.D

Change TypeModified

Effective DateNovember 1, 2026

Next Review DateNot specified

Key ActionEnsure the medical record fully supports medical necessity and includes relevant history, examination, and pertinent diagnostic results.

SourceLink

On This Page

Billing Rule

Bulking Agent Use Must Meet Covered Indication and Labeling

Use injectable bulking agents only for vocal fold insufficiency or dysfunction and in accordance with applicable U.S. Food and Drug Administration (FDA) labeling.

The FDA-labeled indications, contraindications, warnings, and precautions must be followed.

Billing Rule

State Fee Schedule Limitation

Codes marked with an asterisk (*) are not listed on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by the State of New Jersey Medicaid Program.

*G0429 — Dermal filler injection(s) for facial lipodystrophy syndrome.
*Q2026 — Injection, Radiesse, 0.1 ml.
*Q2028 — Injection, Sculptra, 0.5 mg.
L8607 is listed without an asterisk but remains subject to applicable benefit, contractual, and legal requirements; code listing does not guarantee coverage or claim payment.

Vocal Fold Injection Augmentation

DefinitionVocal fold injection augmentation is a procedure used to treat glottal insufficiency by injecting material to improve vocal fold closure.

IndicationsIndications include unilateral vocal fold paralysis or paresis, vocal fold atrophy, vocal fold scar, sulcus vocalis, or loss of vocal fold soft tissue.

ContraindicationsContraindications include unstable cardiopulmonary status; allergy to injectable materials or local anesthetic; poor endolaryngeal exposure due to a prolapsing arytenoid; and severe supraglottic constriction or poorly defined neck anatomy.

Relative contraindicationsRelative contraindications include a large posterior glottal gap or interarytenoid defect requiring framework surgery and treatment with anticoagulants.