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    v1.0.30
    OpenPayerPolicy UpdatesPlastic/Reconstructive SurgeryHealth New England Lipodystrophy Coverage | OpenPa…
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    ModifiedHealth-New-EnglandPolicy UM389POL

    Lipodystrophy Syndrome - HIV Associated - Medical Policy

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    This policy governs prior authorization and medical-necessity review for FDA-approved facial dermal fillers, suction-assisted lipectomy, and other restorative procedures used to correct HIV-associated lipodystrophy for Commercial, Medicare Advantage, and Medicaid members.

    Policy Summary
    PayerHealth-New-England
    PolicyLipodystrophy Syndrome - HIV Associated - Medical Policy
    Policy CodePolicy UM389POL
    Change TypeModified
    Effective DateDecember 1, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization with clinical documentation supporting medical necessity for listed dermal filler and suction-assisted lipectomy procedures.
    SourceLink
    POLICY UPDATE CHANGES

    Medicare requests for dermal injections for facial HIV-associated lipodystrophy are subject to InterQual criteria based on NCD 250.5.

    3Applicable lines of business
    4Core medical-necessity elements

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    7
    Procedure and billing codes
    FDA-approved onlyFiller requirement
    MassachusettsState mandate

    Coverage Criteria

    Medicare dermal injections

    Medicare requests for dermal injections for facial lipodystrophy syndrome must meet HNE-adopted InterQual criteria based on Medicare NCD 250.5.

    Medicare facial dermal injection criteria

    • Apply HNE-adopted InterQual criteria for Procedures, Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS), consistent with Medicare NCD 250.5, Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome.

    Massachusetts statutory coverage mandate

    Massachusetts fully insured health plans must include coverage required by Chapter 233 of the Acts of 2016.

    Mandated treatment types

    • Coverage includes medical or drug treatments to correct or repair disturbances of body composition caused by HIV-associated lipodystrophy syndrome, including reconstructive surgery such as suction-assisted lipectomy, other restorative procedures, and dermal injections or fillers for reversal of facial lipoatrophy syndrome.

    Dermal fillers that are not approved by the FDA for treatment of lipodystrophy syndrome are considered experimental and investigational and are not covered under this policy.

    Fillers for facial lipoatrophy, suction-assisted lipectomy, and other restorative procedures are not medically necessary when the applicable HIV-associated lipodystrophy criteria are not met.

    Fillers for facial lipoatrophy, suction-assisted lipectomy, and other restorative procedures are considered not medically necessary when the member does not have documented lipodystrophy related to highly active antiretroviral therapy, when the resulting physical abnormalities are not established, or when required conservative treatment and pharmacotherapy have not failed or are not inappropriate.

    Treatment is considered not medically necessary for non-HIV-related lipodystrophy syndrome.

    Coding Guidance

    HCPC CodesHCPCS
    G0429Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy).
    CPT CodesCPT
    11950Subcutaneous injection of filling material (eg, collagen); 1 cc or less.
    11951Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc.
    11952Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc.
    11954Subcutaneous injection of filling material (eg, collagen); over 10.0 cc.
    15876Suction lipectomy of head and neck.
    15877Suction lipectomy of trunk.
    15878Suction assisted lipectomy; upper extremity.
    15879Suction assisted lipectomy; lower extremity.
    Historical CPT code referenceCPT
    11953Referenced in policy implementation history; procedure description is not provided in the current document.

    Provider Actions and Review Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required before treatment for listed dermal filler injection and suction-assisted lipectomy procedures. Submit the request through the treating provider before services are rendered.

    • HCPCS G0429 — Dermal filler injection(s) for treatment of facial lipodystrophy syndrome.
    • CPT 11950*, 11951*, 11952*, and 11954* — Subcutaneous injection of filling material.
    • CPT 15876*, 15877*, 15878*, and 15879* — Suction or suction-assisted lipectomy of the head and neck, trunk, upper extremity, or lower extremity.
    Step Therapy

    Required Conservative and Pharmacologic Treatment

    Before treatment is considered medically necessary, conservative treatment and pharmacotherapy must have failed or be inappropriate for the member's condition.

    • Modification of the antiretroviral regimen.

    Clinical Background

    HIV-associated lipodystrophy occurs in people with HIV receiving antiretroviral therapy and may involve central fat accumulation, localized fat loss, or both. Lipoatrophy commonly affects the face, limbs, and buttocks, while lipohypertrophy may involve the dorsocervical fat pad, neck, breasts, or abdominal viscera. These changes may cause disfigurement, stigma, psychological distress, reduced quality of life, and concerns about treatment adherence.

    Definitions

    HIV-associated lipodystrophy
    DefinitionA syndrome occurring in HIV-infected patients treated with antiretroviral medications.
    Central fat accumulationMay cause abnormal central fat accumulation, also called lipohypertrophy.
    Localized fat lossMay cause localized loss of fat tissue, also called lipoatrophy.
    Clinical presentationSome patients have only lipohypertrophy or only lipoatrophy; less commonly, both occur together as a mixed presentation.
    Lipohypertrophy syndrome
    DefinitionAbnormal central fat accumulation associated with HIV-associated lipodystrophy.
    Policy Summary
    PayerHealth-New-England
    PolicyLipodystrophy Syndrome - HIV Associated - Medical Policy
    Policy CodePolicy UM389POL
    Change TypeModified
    Effective DateDecember 1, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization with clinical documentation supporting medical necessity for listed dermal filler and suction-assisted lipectomy procedures.
    SourceLink
    On This Page
    Coverage CriteriaCoding GuidanceProvider Actions and Review RequirementsClinical BackgroundDefinitions
  1. Diet and exercise.
  2. Pharmacotherapy with pioglitazone, metformin, or tesamorelin.

    3. Unsupported block type: documentation

    Unsupported block type: documentation

    Denial Risk

    Denial Risk: Criteria Not Met or Non-HIV-Related Condition

    Fillers for facial lipoatrophy, suction-assisted lipectomy, and other restorative procedures are not medically necessary when the applicable HIV-associated antiretroviral-related lipodystrophy criteria are not met or when the lipodystrophy syndrome is not HIV-related.

    • Criteria not met.
    • Non-HIV-related lipodystrophy syndrome.
    Denial Risk

    Non-FDA-Approved Filler

    Dermal fillers that are not approved by the FDA for treatment of lipodystrophy syndrome are considered experimental and investigational.

    • Verify that the proposed filler has FDA approval for the treatment of lipodystrophy syndrome.
    Documentation Required

    Insufficient Clinical Documentation

    Requests without sufficient clinical evidence and medical-necessity information cannot be properly reviewed for prior authorization. Submit the documentation needed to demonstrate that the member meets the treatment criteria.

    • Include clinical evidence from the treating physician or primary care provider.
    • Explain how the proposed treatment corrects, repairs, or ameliorates the effects of HIV-associated lipodystrophy syndrome.
    • Incomplete documentation may prevent Health New England from properly reviewing the request.
    Dorsocervical fat pad
    Enlargement of the dorsocervical fat pad.
    NeckCircumferential expansion of the neck.
    BreastsBreast enlargement.
    AbdomenAccumulation of abdominal visceral fat.
    Lipoatrophy syndrome
    DefinitionPeripheral fat wasting with loss of subcutaneous tissue.
    FaceProgressive loss of facial fat; decreased malar and temporal fat may create deep skin furrows and an aged or wasting appearance.
    ExtremitiesLoss of subcutaneous tissue in the arms and legs.
    ButtocksLoss of subcutaneous tissue in the buttocks.