CurrentUnitedHealthcarePolicy CS371PA.C

Injectable Dermal Fillers and Bulking Agents (for Pennsylvania Only)

Coverage rules for injectable dermal fillers and vocal fold bulking agents for members in Pennsylvania, including medical necessity determinations and documentation requirements for providers.

Policy Summary

PayerUnitedHealthcare

PolicyInjectable Dermal Fillers and Bulking Agents (for Pennsylvania Only)

Policy CodePolicy CS371PA.C

Change TypeCode additions and documentation clarifications

Effective DateJan 1, 2026

Next Review Date

Key ActionEnsure patient medical records fully document medical necessity, including history, exam, and relevant test results, to support requests.

SourceLink

POLICY UPDATE CHANGES

Medical records documentation language was added to clarify that benefit coverage is determined by federal, state, or contractual requirements and that documentation may be required to assess medical necessity.

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

Description of Services section was updated to reflect current information on HIV facial lipoatrophy and vocal fold insufficiency.

PAjurisdiction/applicability

Radiesse, Sculptrareconstructive fillers (HIV)

Other fillerscosmetic / not medically necessary

Covered per FDA

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vocal fold bulking agents

3new CPT procedure codes

Coverage Criteria

Medical necessity criteria

Covered when the specific conditions and product labeling are met:

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

These products are FDA-approved for correction of facial lipoatrophy in people with HIV (see FDA approvals).

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

Radiesse and Sculptra are not covered for non‑HIV indications; other fillers are considered cosmetic.

Vocal fold insufficiency - bulking agents: 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.

Includes bulking agents cleared via 510(k) for vocal cord medialization.

Radiesse and Sculptra are cosmetic and not medically necessary for all indications other than HIV-related facial lipoatrophy. The use of any dermal filler product other than Radiesse or Sculptra for indications other than HIV facial lipoatrophy is considered cosmetic and not medically necessary.

Radiesse (calcium hydroxylapatite) and Sculptra (poly-L-lactic acid) are considered reconstructive and medically necessary when used for the treatment of facial defects due to facial lipoatrophy in individuals living with HIV. For all other indications, including cosmetic facial augmentation in non-HIV patients, Radiesse and Sculptra are considered not medically necessary.

Applicable Codes

Covered CPT Codes (laryngeal injection procedures)CPTCovered

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.

Covered HCPCS/G codes (HIV facial lipoatrophy)HCPCSCovered

G0429

Dermal Filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy).

Covered HCPCS/Q codes (products)HCPCSCovered

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 Billing Rules

Prior Authorization

Prior Authorization Required

Prior authorization is required when applicable per UnitedHealthcare benefit plan terms. Verify member eligibility and benefit coverage before scheduling procedures; inclusion of a procedure code in this policy does not guarantee coverage or payment.

Applicable to services in Pennsylvania per policy application
Confirm prior authorization requirements through payer portals or contact centers

Billing Rule

Billing/Coding Guidance

Providers must submit complete and accurate claims using the most specific applicable codes. Refer to the Applicable Codes section for CPT, HCPCS, and other codes listed in this policy. Listing a code here is for reference only and does not imply coverage.

Background

HIV-associated facial lipoatrophy is a recognized consequence of HIV infection and its treatment; FDA‑approved injectable fillers such as Radiesse and Sculptra have indications for correction of facial fat loss in people living with HIV. These products are therefore treated as reconstructive for that specific indication, while dermal fillers used for other, non-HIV cosmetic purposes are considered not medically necessary.

Definitions

Vocal fold insufficiency — condition definition

DefinitionA condition in which one or both vocal cords do not close properly, leading to vocal fatigue, poor voice quality or tone, difficulty speaking, swallowing, or coughing, and increased risk of laryngeal penetration, aspiration, and pneumonia.

Also Known AsVocal cord dysfunction; paradoxical vocal fold movement; glottal insufficiency.

Clinical ConsequencesMay cause vocal fatigue, poor voice quality, swallowing difficulty, and increased aspiration risk.

Common TreatmentsVoice therapy, thyroplasty, or vocal fold injection with a bulking agent to medialize the affected fold.

Injectable fillers (Sculptra, Radiesse) indications summary

Products and CompositionSculptra (poly-L-lactic acid) and Radiesse (calcium hydroxylapatite/carboxymethylcellulose-based microspheres).

Policy Summary

PayerUnitedHealthcare

PolicyInjectable Dermal Fillers and Bulking Agents (for Pennsylvania Only)

Policy CodePolicy CS371PA.C

Change TypeCode additions and documentation clarifications

Effective DateJan 1, 2026

Next Review Date

Key ActionEnsure patient medical records fully document medical necessity, including history, exam, and relevant test results, to support requests.

SourceLink

On This Page

CPT codes added: 31570, 31571, 31574

HCPCS/CPT II/NDC examples in Applicable Codes: G0429, L8607, Q2026, Q2028

Documentation Required

Medical Record Documentation — Examples and Expectations

Medical records documentation must fully support the medical necessity of the requested service. Documentation should be legible, maintained in the patient record, and made available upon request. Required documentation may be requested during review and is used to determine if coverage criteria are met; providing documentation does not guarantee coverage.

Include relevant medical history, focused physical examination, and results of pertinent diagnostic tests or procedures
Document clinical rationale linking findings to the requested procedure and expected benefit
Maintain legible records and supply them promptly upon payer request

Denial Risk

Documentation-Related Denial Risk

Incomplete or missing documentation is a common reason for claim or prior authorization denials. Ensure submitted records directly support the clinical criteria and billing codes to reduce denial risk.

Denials may occur if documentation is illegible, contradictory, or lacks diagnostic test results cited as justification
Service may be denied if benefit, state law, or contractual requirements are not met despite documentation submission
If a service is provided outside the Pennsylvania application scope, it may be reviewed case-by-case and denied if not covered

FDA-Approved IndicationBoth Sculptra and Radiesse are FDA-approved to correct facial fat loss (facial lipoatrophy) in people living with HIV.

Coverage StanceRadiesse and Sculptra are considered reconstructive and medically necessary for facial defects due to HIV-related facial lipoatrophy; they are cosmetic and not medically necessary for all other indications.

Other FillersUse of dermal filler products other than Radiesse or Sculptra for indications other than HIV facial lipoatrophy is considered cosmetic and not medically necessary.

Evidence/ContextHIV-associated facial lipoatrophy affects ~50% of patients on HAART and can have significant psychosocial impact; FDA approvals date to 2004 (Sculptra) and 2006 (Radiesse).