Currentsierra health and lifePolicy 2026T0650F

Injectable Dermal Fillers and Bulking Agents

Defines medical necessity and coverage stance for injectable dermal fillers for facial lipoatrophy in people with HIV and for injectable bulking agents for vocal fold insufficiency; applies to UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

Payersierra health and life

PolicyInjectable Dermal Fillers and Bulking Agents

Policy CodePolicy 2026T0650F

Change TypeTemplate Update

Effective DateJan 1, 2026

Next Review Date

Key ActionVerify member-specific benefit plan for prior authorization and document required medical records to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medically necessaryRadiesse and Sculptra

Not medically necessaryOther dermal fillers

Medically necessaryInjectable bulking agents

Approx. 50%HAART-treated patients

CPT/HCPCS listedProcedure codes

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Coverage Criteria

Dermal fillers — HIV facial lipoatrophy

Covered when meeting indication-specific criteria:

HIV facial lipoatrophy - Radiesse and Sculptra: Radiesse and Sculptra are considered reconstructive and medically necessary for treatment of facial defects due to facial lipoatrophy in individuals living with HIV infection.

Other dermal filler products are considered cosmetic and not medically necessary for all other indications.

Injectable bulking agents — vocal fold insufficiency

Covered when used per FDA labeled indications:

Injectable bulking agents for vocal fold insufficiency: Injectable bulking agents are proven and medically necessary for treatment of vocal fold insufficiency/dysfunction when used according to FDA labeled indications, contraindications, warnings, and precautions.

Refer to FDA 510(k) clearances for specific products (product code MIX).

Radiesse and Sculptra are the only dermal filler products identified in this policy as reconstructive and medically necessary for the treatment of facial defects due to facial lipoatrophy in individuals living with HIV. All other dermal filler products are considered cosmetic and not medically necessary for this indication and for all other indications.

This Medical Policy is a guide to interpreting UnitedHealthcare standard benefit plans. The terms of the member specific benefit plan document must be referenced when deciding coverage because they may differ from this policy. In the event of a conflict between this Medical Policy and a member specific benefit plan, the member specific benefit plan governs.

Except for Radiesse and Sculptra when used for HIV-related facial lipoatrophy, the use of all other dermal filler products is considered cosmetic and not medically necessary.

Coding and Billing Reference

Procedure and supply codes referencedmixed

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) (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

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization may be required. Verify prior authorization requirements with the member-specific benefit plan before scheduling services.

Affected codes: 31570, 31571, 31574, G0429, L8607, Q2026, Q2028

Denial Risk

Documentation and Denial Risk

Document medical necessity thoroughly. Medical records documentation may be required to demonstrate that the member meets the clinical criteria for coverage. Lack of required documentation may result in denial of the request.

Include relevant clinical notes, diagnostic findings, and procedure indications
Attach prior authorization requests and any supporting imaging or specialty evaluations when applicable

Background

Facial lipoatrophy associated with HIV and antiretroviral therapy can produce visible loss of subcutaneous facial fat and is reported to affect a substantial proportion of treated patients, with significant psychosocial consequences. For treatment of facial defects due to HIV-related facial lipoatrophy, this policy recognizes FDA-cleared products Sculptra (poly-L-lactic acid) and Radiesse (calcium hydroxylapatite) as reconstructive and medically necessary options when used for that indication.

Definitions

Definition — Vocal fold insufficiency (glottal insufficiency)

TermVocal fold insufficiency (glottal insufficiency)

DefinitionA condition in which one or both vocal cords do not open or close correctly, leading to poor glottic closure with symptoms such as vocal fatigue, poor voice quality or tone, difficulty speaking, swallowing, or coughing.

Clinical risksIncreased risk of laryngeal penetration, aspiration, and pneumonia.

Common treatmentsVoice therapy, thyroplasty, or vocal fold injection with injectable bulking agents to medialize the affected fold.

Definition — HIV facial lipoatrophy (associated with HAART)

TermHIV facial lipoatrophy (associated with HAART)