CurrentColorado Rocky Mountain Health PlansPolicy CS371OH.C

Injectable Dermal Fillers and Bulking Agents (for Ohio Only)

State-specific Ohio medical policy governing when injectable dermal fillers and injectable bulking agents are considered medically necessary versus cosmetic, with applicable CPT/HCPCS codes and documentation requirements. Applies only to Ohio and references Ohio Administrative Code for unproven or limited services.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyInjectable Dermal Fillers and Bulking Agents (for Ohio Only)

Policy CodePolicy CS371OH.C

Change TypeDocumentation, Codes, Description updates

Effective DateJan 1, 2026

Next Review Date

Key ActionMedical records must fully support medical necessity including relevant medical history, physical exam, and pertinent diagnostic test/procedure results; documentation must be legible, maintained in the chart, and made available upon request.

SourceLink

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews section language added clarifying documentation requirements and that documentation does not guarantee coverage.

CPT codes 31570, 31571, and 31574 were added to Applicable Codes.

Description of Services updated to reflect most current information.

2Dermal filler agents considered medically necessary (Radiesse, Sculptra)

1Clinical indication covered for dermal fillers (HIV-associated facial lipoatrophy)

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Coverage Summary

This is the Ohio-specific coverage policy CS371OH.C for Injectable Dermal Fillers and Bulking Agents. Scope: State-specific Ohio medical policy governing when injectable dermal fillers and injectable bulking agents are considered medically necessary versus cosmetic, with applicable CPT/HCPCS codes and documentation requirements. Applies only to Ohio and references Ohio Administrative Code for unproven or limited services. Background: Radiesse and Sculptra are addressed as treatments for HIV-associated facial lipoatrophy and injectable bulking agents are addressed for vocal fold medialization. Policy number: CS371OH.C. Coverage stance: mixed. Status: CURRENT.

Key Policy Facts

Policy numberCS371OH.C

ScopeOhio-only

SubjectInjectable dermal fillers and bulking agents

Effective date2026-01-01

Last review2026-01-01

Medical Necessity Criteria

Dermal Filler Injections — Medically Necessary

Covered when ALL of the following are met:

ALL of the following

Agent is Radiesse or Sculptra
Indication is treatment of facial defects due to facial lipoatrophy in individuals living with human immunodeficiency virus (HIV) infection

FDA Info

Dermal Filler Injections — Not Medically Necessary

Not covered when ANY of the following apply:

ANY of the following

Use of Radiesse or Sculptra for all other indications (i.e., indications other than HIV-associated facial lipoatrophy)

Applicable Codes

Relevant CPT codes (reference only)CPT

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

Dermal filler / related HCPCSHCPCS

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

Note: CPT codes 31570, 31571, and 31574 were added to the Applicable Codes list and are included for reference only. The HCPCS codes listed for dermal filler and bulking agents include G0429 (dermal filler for facial lipodystrophy), L8607 (injectable bulking agent for vocal cord medialization), and product-specific codes Q2026 (Radiesse) and Q2028 (Sculptra).

Provider Actions & Documentation

Documentation Required

Medical record documentation required

Medical records must fully support medical necessity including relevant medical history, physical exam, and pertinent diagnostic test/procedure results; documentation must be legible, maintained in the chart, and made available upon request.

Prior Authorization

Ohio-specific evaluation for unproven/limited services

Requests for services stated as unproven or with coverage/quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01.

Actionable note: Medical records documentation may be required to assess whether the member meets clinical criteria for coverage but does not guarantee coverage. Requests for services that are stated as unproven or that have coverage/quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01; documentation must fully support medical necessity and be made available upon request.

Background & Evidence

Background: The FDA has approved Radiesse and Sculptra for treatment of facial lipoatrophy in people with HIV, and a number of bulking agents have been cleared by the FDA for vocal cord medialization. HIV-associated facial lipoatrophy affects up to approximately 50% of patients treated with HAART and can cause significant psychosocial morbidity. Vocal fold injection (medialization) is an option for glottal insufficiency to improve voice quality and to reduce risk of aspiration by injecting a bulking agent to align the affected fold with the opposing fold.

Citation	Key finding
Vallejo et al. (2018)
Objective improvement in facial lipoatrophy reported in 53% of cases; autologous fat had lower costs
Jagdeo et al. (2015)
Systematic review: poly-L-lactic acid (Sculptra) assigned B-level recommendation; calcium hydroxylapatite (CaHA, Radiesse) assigned C-level recommendation for HIV facial lipoatrophy
Carroll & Rosen (2011)
Average length of benefit from CaHA vocal fold injection was 18.6 months (range 8–36 months); 64% showed loss of benefit by follow-up in the included subset

Vocal fold insufficiency: Condition where one or both vocal cords do not close properly causing voice, swallowing, and aspiration risk; also called glottal insufficiency.

Revision History

2026-01-01addedLatest

Medical Records Documentation Used for Reviews section language added clarifying documentation requirements and that documentation does not guarantee coverage; specifies required elements (relevant medical history, physical exam, pertinent diagnostic test/procedure results), legibility, chart retention, and availability upon request.

2026-01-01addedLatest

CPT codes 31570, 31571, and 31574 were added to Applicable Codes (laryngoscopy with injection procedures).