ModifiedKaiser PermanentePolicy N/A

Dermal Fillers for Facial Lipoatrophy

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Coverage of FDA-approved dermal filler injections for HIV- or HAART-associated facial lipodystrophy/lipoatrophy, subject to applicable plan benefits and coverage criteria.

Policy Summary

PayerKaiser Permanente

PolicyDermal Fillers for Facial Lipoatrophy

Policy CodePolicy N/A

Change TypeModified

Effective DateDecember 1, 2026

Last ReviewMar 3, 2026

Next Review DateN/A

Key ActionSubmit dermal filler injection requests for clinical review with the required clinical documentation.

SourceLink

POLICY UPDATE CHANGES

Effective December 1, 2026, coverage eligibility expands from Carruthers grades 3-4 to grades 2-4 facial lipodystrophy/lipoatrophy.

The policy adds grade-specific quantity limits of up to 2 sessions for grade 2, up to 4 sessions for grade 3, and up to 8 sessions for grade 4.

Kaiser Permanente adopted Kaiser Permanente National clinical criteria for Dermal Fillers for Facial Lipoatrophy effective December 1, 2026.

The policy adopts Kaiser Permanente National clinical criteria for Dermal Fillers for Facial Lipoatrophy.

Coverage criteria were approved for non-Medicare members.

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ModifiedKaiser PermanentePolicy N/A

Dermal Fillers for Facial Lipoatrophy

Customize your policy alerts

Sign up for all Kaiser Permanente policy alerts

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Coverage of FDA-approved dermal filler injections for HIV- or HAART-associated facial lipodystrophy/lipoatrophy, subject to applicable plan benefits and coverage criteria.

Policy Summary

PayerKaiser Permanente

PolicyDermal Fillers for Facial Lipoatrophy

Policy CodePolicy N/A

Change TypeModified

Effective DateDecember 1, 2026

Last ReviewMar 3, 2026

Next Review DateN/A

Key ActionSubmit dermal filler injection requests for clinical review with the required clinical documentation.

SourceLink

POLICY UPDATE CHANGES

Effective December 1, 2026, coverage eligibility expands from Carruthers grades 3-4 to grades 2-4 facial lipodystrophy/lipoatrophy.

The policy adds grade-specific quantity limits of up to 2 sessions for grade 2, up to 4 sessions for grade 3, and up to 8 sessions for grade 4.

Kaiser Permanente adopted Kaiser Permanente National clinical criteria for Dermal Fillers for Facial Lipoatrophy effective December 1, 2026.

The policy adopts Kaiser Permanente National clinical criteria for Dermal Fillers for Facial Lipoatrophy.

Coverage criteria were approved for non-Medicare members.

Grades 2-4Covered facial lipoatrophy severity range

Grade 1Severity grade not covered

2 / 4 / 8Maximum sessions for grades 2 / 3 / 4

1-2 yearsRepeat treatment interval

3Applicable filler codes

Coverage Criteria

Initial coverage criteria

Covered when ALL of the following are met:

Eligible condition
- The member has a diagnosis of human immunodeficiency virus (HIV).
- The member has facial lipodystrophy/lipoatrophy, grades 2-4, related to HIV or highly active antiretroviral therapy (HAART).Grades 2-4
Approved product: The dermal filler is approved by the Food and Drug Administration for Facial Lipodystrophy Syndrome (LDS), such as Sculptra or Radiesse.FDA approval for Facial Lipodystrophy Syndrome

Grading and quantity limits

Quantity limits depend on the patient’s Carruthers Lipoatrophy Severity Scale grade.

Grade-specific session limits

Grade 2: For grade 2 facial lipoatrophy, up to 2 sessions are covered.Grade 2; up to 2 sessions
Grade 3: For grade 3 facial lipoatrophy, up to 4 sessions are covered.Grade 3; up to 4 sessions
Grade 4: For grade 4 facial lipoatrophy, up to 8 sessions are covered.Grade 4; up to 8 sessions

Repeat treatment

Repeat treatment may be considered when the following condition is met:

Repeat treatment consideration: Repeat treatment is typically necessary one to two years after initial therapy when the patient has regressed to grade 2 or greater lipoatrophy.Grade 2 or greater; typically 1-2 years after initial therapy

For additional treatment, the treating provider must reevaluate the patient or provide repeat facial photographs to determine whether further treatment is warranted.

Medical necessity for applicable codes

Applicable codes are considered medically necessary when the following requirement is met:

Applicable policy criteria: The criteria in the applicable policy statements listed above must be met for the listed dermal filler services to be considered medically necessary.

Applicable services include dermal filler injection(s) for facial lipodystrophy syndrome and the listed Radiesse and Sculptra injection codes.

Coverage is excluded in the presence of coagulopathy, active infection whether or not it is related to HIV disease, or inadequate immune function as determined by the HIV provider.

The use of injectable poly-L-lactic acid for treatment of facial lipoatrophy does not meet the Kaiser Permanente Medical Technology Assessment Criteria.

Grade 1 facial lipoatrophy is not covered. Grade 1 represents mild facial fat loss under the Carruthers Lipoatrophy Severity Scale.

Injectable poly-L-lactic acid treatment for facial lipoatrophy is not considered to meet the Kaiser Permanente Medical Technology Assessment Criteria.

Applicable Codes and Quantity Limits

Covered HCPCS CodesHCPCSCovered

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.

Covered HCPCS CodesHCPCSCovered

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.

Grade 2 quantity limit

Severity gradeGrade 2 facial lipoatrophy

Maximum covered sessionsUp to 2 sessions

Clinical descriptionDeeper concavity of the cheeks; facial lipoatrophy visible to others

Grade 3 quantity limit

Severity gradeGrade 3 facial lipoatrophy

Maximum covered sessionsUp to 4 sessions

Clinical description

Authorization and Documentation Requirements

Prior Authorization

Submit for Authorization Review

Submit the service for authorization review before treatment. Verify authorization requirements for the member’s plan using the Pre-authorization Code Check; applicable codes are considered medically necessary only when the policy criteria are met.

G0429 — Dermal filler injection(s) for treatment of facial lipodystrophy syndrome (LDS), such as from highly active antiretroviral therapy
Q2026 — Injection, Radiesse, 0.1 mL
Q2028 — Injection, Sculptra, 0.5 mg

Documentation Required

Submit Six Months of Clinical Notes

For a review request, submit the last six months of clinical notes from the requesting provider and/or specialist.

Clinical Background

HIV-associated lipodystrophy can involve loss of subcutaneous fat in the face, including the nasolabial regions, temples, and eye sockets. Facial lipoatrophy is distinct from HIV wasting syndrome, which primarily involves loss of muscle mass. Dermal fillers such as Sculptra and Radiesse may be used to restore facial volume in eligible patients with HIV-associated Facial Lipodystrophy Syndrome.

Definitions and Severity Scale

Carruthers Lipoatrophy Severity Scale (CLSS)

Scale rangeGrade 1 through Grade 4

InterpretationHigher scores indicate greater severity of facial fat loss

Grade 1Mild severity

Grade 2Moderate severity

Grade 3Severe severity

Grade 4Very severe severity

Facial lipodystrophy/lipoatrophy

Policy Summary

PayerKaiser Permanente

PolicyDermal Fillers for Facial Lipoatrophy

Policy CodePolicy N/A

Change TypeModified

Effective DateDecember 1, 2026

Last ReviewMar 3, 2026

Next Review DateN/A

Key ActionSubmit dermal filler injection requests for clinical review with the required clinical documentation.

SourceLink

On This Page

Deep concavity with prominent facial skeletal landmarks

Grade 4 quantity limit

Severity gradeGrade 4 facial lipoatrophy

Maximum covered sessionsUp to 8 sessions

Clinical descriptionNear-total or total loss of facial fat, with severe skeletal prominence

Grade 1 coverage threshold

Severity gradeGrade 1 facial lipoatrophy

Coverage statusNot covered

Clinical descriptionMild facial flattening or shallow concavity, typically noticeable only to the patient or trained observer

Documentation Required

Support Additional Treatment Requests

For additional treatment sessions, reevaluate the patient or repeat facial photographs to establish that further treatment is warranted. Treatment limits depend on Carruthers Lipoatrophy Severity Scale (CLSS) grade, and repeat treatment is typically needed one to two years after initial therapy when lipoatrophy has regressed to Grade 2 or greater.

Grade 1: treatment is not covered
Grade 2: up to 2 sessions
Grade 3: up to 4 sessions
Grade 4: up to 8 sessions

Denial Risk

Watch for Coverage Denial Conditions

Coverage may be denied when the member does not meet all coverage criteria or has an applicable exclusion. The member must have HIV and Grade 2–4 facial lipodystrophy/lipoatrophy related to HIV or HAART, and the filler must be FDA-approved for Facial Lipodystrophy Syndrome.

Exclusions include coagulopathy, active infection whether or not related to HIV disease, and inadequate immune function as determined by the HIV provider
Grade 1 facial lipoatrophy is not covered
Examples of FDA-approved fillers include Sculptra® and Radiesse®

Denial Risk

PLA Fails Technology Assessment Criteria

Poly-L-lactic acid (PLA) treatment for facial lipoatrophy does not meet Kaiser Permanente Medical Technology Assessment Criteria and may be denied or considered non-covered.

Loss of facial subcutaneous fat

Associated conditionHuman immunodeficiency virus (HIV) infection

Associated treatmentHighly active antiretroviral therapy (HAART)

Facial Lipodystrophy Syndrome (LDS)

DefinitionFacial Lipodystrophy Syndrome (LDS)

Filler requirementThe dermal filler must be approved by the Food and Drug Administration for Facial Lipodystrophy Syndrome

ExamplesSculptra® and Radiesse®