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    v1.0.28
    OpenPayerPolicy UpdatesOtorhinolaryngology (ENT)UnitedHealthcare Dermal Filler Coverage | OpenPaye…
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    CurrentUnitedHealthcarePolicy CS371NE.D

    Injectable Dermal Fillers and Bulking Agents (for Nebraska Only)

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    This policy governs coverage of injectable dermal fillers and bulking agents for UnitedHealthcare Community Plan members in Nebraska, including dermal fillers for HIV-associated facial lipoatrophy and injectable bulking agents for vocal fold insufficiency or dysfunction.

    Policy Summary
    PayerUnitedHealthcare
    PolicyInjectable Dermal Fillers and Bulking Agents (for Nebraska Only)
    Policy CodePolicy CS371NE.D
    Change TypeSupporting-information updateno material clinical or coverage change
    Effective DateOctober 1, 2026
    Next Review DateNot specified
    Key ActionEnsure the medical record includes the relevant medical history, physical examination, and pertinent diagnostic test or procedure results to support medical necessity.
    SourceLink
    POLICY UPDATE CHANGES

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

    NebraskaApplicable state
    2Medically necessary dermal filler products

    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.

    FDA-labeledRequired use for injectable bulking agents
    All otherOther dermal fillers considered cosmetic
    2CPT codes listed
    4HCPCS codes listed

    Medical Necessity and Coverage Criteria

    Dermal Filler Coverage

    Covered as reconstructive and medically necessary when both the product and clinical indication requirements are met.

    Radiesse or Sculptra for HIV-associated facial lipoatrophy: The treatment uses Radiesse or Sculptra and addresses facial defects due to facial lipoatrophy in an individual living with human immunodeficiency virus (HIV) infection.

    Both the product and HIV-associated facial lipoatrophy indication are required.

    Injectable Bulking Agent Coverage

    Covered when the following condition is met.

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

    Use outside FDA-labeled requirements may be denied.

    Radiesse and Sculptra are considered cosmetic and not medically necessary for indications other than facial defects due to facial lipoatrophy in individuals living with HIV infection.

    All dermal filler products other than Radiesse and Sculptra are considered cosmetic and not medically necessary.

    Use of Radiesse or Sculptra for indications outside facial defects due to facial lipoatrophy in individuals living with HIV infection is not medically necessary.

    Use of dermal filler products other than Radiesse and Sculptra is not medically necessary.

    CPT and HCPCS Codes

    CPT CodesCPT
    31571Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or
    31574Laryngoscopy, flexible; with injection(s) for augmentation (e.g., percutaneous, transoral), unilateral
    HCPCS CodesHCPCS
    G0429Dermal Filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy).
    L8607Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies.
    Q2026Injection, Radiesse, 0.1ml.
    Q2028Injection, Sculptra, 0.5 mg.

    Documentation and Denial Risks

    Documentation Required

    Medical Necessity Records

    The patient's medical record must contain documentation that fully supports the medical necessity of the requested services. Records must be legible, maintained in the medical record, and made available upon request; documentation may be required to assess coverage but does not guarantee coverage.

    • Relevant medical history
    • Physical examination
    • Results of pertinent diagnostic tests or procedures
    • Any other supporting documentation demonstrating medical necessity
    Denial Risk

    Non-HIV Dermal Filler Indications

    Radiesse and Sculptra are considered reconstructive and medically necessary only for facial defects due to facial lipoatrophy in individuals living with HIV. Their use for all other indications is considered cosmetic and not medically necessary.

    Clinical Background

    HIV-associated facial lipoatrophy is facial fat loss that may occur in individuals receiving highly active antiretroviral therapy. Radiesse and Sculptra are FDA-approved fillers for this indication.

    Clinical Definitions

    Vocal cord insufficiency
    ConditionA condition in which one or both vocal cords do not open correctly.
    Glottic closureWhen the glottis does not close properly, vocal symptoms may occur.
    Associated symptomsVocal fatigue; poor voice quality or tone; and difficulty speaking, swallowing, or coughing.
    Potential complicationsIncreased risk for larynx penetration, aspiration, and pneumonia.
    Vocal fold insufficiency
    Alternate termVocal cord dysfunction.
    Alternate term
    Policy Summary
    PayerUnitedHealthcare
    PolicyInjectable Dermal Fillers and Bulking Agents (for Nebraska Only)
    Policy CodePolicy CS371NE.D
    Change TypeSupporting-information updateno material clinical or coverage change
    Effective DateOctober 1, 2026
    Next Review DateNot specified
    Key ActionEnsure the medical record includes the relevant medical history, physical examination, and pertinent diagnostic test or procedure results to support medical necessity.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaCPT and HCPCS CodesDocumentation and Denial RisksClinical BackgroundClinical Definitions
    • Non-HIV indications are not medically necessary.
    • Other indications, including uses unrelated to HIV-associated facial lipoatrophy, may be denied.
    Denial Risk

    Other Dermal Filler Products

    The use of all dermal filler products other than Radiesse and Sculptra is considered cosmetic and not medically necessary.

    • Other dermal filler products are not covered as medically necessary under this policy.
    Denial Risk

    Use Outside FDA Labeling

    Injectable bulking agents may be denied when used outside the applicable U.S. Food and Drug Administration-labeled indication.

    • Confirm that the requested use is within U.S. Food and Drug Administration labeling.
    Paradoxical vocal fold movement.
    Alternate termGlottal insufficiency.
    Policy descriptionA condition in which one or both vocal cords do not open correctly.
    HIV-associated facial lipoatrophy
    DefinitionFacial fat loss associated with HIV infection and highly active antiretroviral therapy.
    PopulationIndividuals living with HIV who are being treated with highly active antiretroviral therapy.
    FDA-approved fillersSculptra and Radiesse are injectable fillers approved to treat facial lipoatrophy in individuals living with HIV.