CurrentUnitedHealthcarePolicy CS371NE.C

Injectable Dermal Fillers and Bulking Agents (for Nebraska Only)

Defines medical necessity and coverage stance for injectable dermal fillers and injectable bulking agents for vocal fold medialization for UnitedHealthcare members in Nebraska. Affects providers performing filler injections and vocal fold injections and billing for related CPT/HCPCS codes.

Policy Summary

PayerUnitedHealthcare

PolicyInjectable Dermal Fillers and Bulking Agents (for Nebraska Only)

Policy CodePolicy CS371NE.C

Change TypeMaterial and technical updates (documentation expectationscode list additions)

Effective DateJan 1, 2026

Next Review Date

Key ActionEnsure the patient medical record contains relevant history, physical exam, and diagnostic test results to support medical necessity and make documentation available upon request.

SourceLink

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews language added specifying documentation expectations for medical necessity determinations.

CPT codes 31570, 31571, and 31574 were added to the applicable codes list.

Description of Services section updated to reflect current information.

50%est. proportion with significant HIV-related lipoatrophy

18.6 moavg benefit duration for CaHA vocal fold injection

64%loss of benefit in small CaHA series

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further treatment rate at 12 months

Coverage Criteria for Injectable Fillers and Bulking Agents

Dermal Fillers — HIV-associated facial lipoatrophy

Covered when ALL of the following are met

Dermal fillers for HIV facial lipoatrophy: Radiesse and Sculptra (and FDA‑approved fillers for HIV‑associated facial lipoatrophy) are considered reconstructive and medically necessary for treatment of facial defects due to facial lipoatrophy in individuals living with human immunodeficiency virus (HIV).

Radiesse and Sculptra are considered cosmetic and not medically necessary for all other indications; the use of all other dermal filler products is considered cosmetic and not medically necessary.

Injectable Bulking Agents — Vocal Fold Medialization

Covered when ALL of the following are met

Injectable bulking agents for vocal fold insufficiency: Injectable bulking agents are proven and medically necessary for the treatment of vocal fold insufficiency/dysfunction when used according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions.

Refer to device‑specific FDA 510(k) clearances for eligible products.

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

Radiesse and Sculptra are considered cosmetic and not medically necessary for all indications other than treatment of facial lipoatrophy due to HIV. These products are considered reconstructive and medically necessary only for facial defects from HIV-associated facial lipoatrophy.

Applicable Codes and Coding Notes

Applicable procedure and HCPCS/CPT codesmixed

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

Average length of benefit for CaHA vocal fold injection

Average length of benefit18.6 months (range 8–36 months)

Proportion showing loss of benefit64% of subjects in the reported series

Cohort size (included injections)20 patients with 22 injections met inclusion criteria

Reported complications3 complications identified among original cohort of 108 injections

Provider Billing, Authorization, and Documentation Requirements

Prior Authorization

Prior Authorization and Code Guidance

Prior authorization requirements are governed by the member's plan, state, or contractual terms. Codes listed in this policy are provided for reference and may not reflect plan-specific authorization requirements. Providers should verify prior authorization and coverage rules with the member's benefit plan before rendering services.

Prior authorization governed by plan, state, or contractual terms
Codes in this policy are for reference only and do not guarantee coverage or authorization

Step Therapy

No explicit step therapy requirements are specified within this policy. Clinicians and providers should reference the member's specific plan tools (for example, InterQual or plan-specific step therapy lists) and the applicable benefit contract to determine any step therapy or trial-of-therapy requirements prior to authorization or billing.

No policy-level step therapy specified — check plan-specific tools and benefit contract

Clinical Background and Rationale

Facial lipoatrophy associated with HIV can cause facial defects that may be treated with injectable dermal fillers. Radiesse and Sculptra are recognized in this policy as reconstructive and medically necessary for treatment of facial lipoatrophy in individuals living with HIV; other dermal filler products are considered cosmetic and not medically necessary.

Definitions

Vocal fold insufficiency

DefinitionVocal fold insufficiency: a condition in which one or both vocal cords do not close or move correctly, causing vocal fatigue, poor voice quality, and potential swallowing/aspiration risk

Common consequencesDifficulty speaking, swallowing, coughing; increased risk of laryngeal penetration, aspiration, and pneumonia

Treatment optionsVoice therapy, thyroplasty, or injectable bulking agents (vocal fold injection) to improve glottal closure

Mechanism of injectionInjection of a bulking agent into the affected fold to assist alignment with the opposing fold

Sculptra / Radiesse

Sculptra (poly-L-lactic acid)FDA-approved injectable filler to correct facial fat loss in people with HIV (approved August 3, 2004)

Policy Summary

PayerUnitedHealthcare

PolicyInjectable Dermal Fillers and Bulking Agents (for Nebraska Only)

Policy CodePolicy CS371NE.C

Change TypeMaterial and technical updates (documentation expectationscode list additions)

Effective DateJan 1, 2026

Next Review Date

Key ActionEnsure the patient medical record contains relevant history, physical exam, and diagnostic test results to support medical necessity and make documentation available upon request.

SourceLink

On This Page

Documentation Required

Required Medical Record Documentation

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. This documentation should be legible, maintained in the patient's medical record, and made available upon request. Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the services requested.

Documentation must include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures
Medical records may be requested to verify that clinical criteria for coverage are met

Denial Risk

Documentation-Related Denial Risk

Lack of adequate medical record documentation supporting medical necessity may result in denial of the request or claim. Denials can occur when documentation is incomplete, illegible, absent, or does not demonstrate that the clinical criteria or benefit terms were met.

Denial risk if history, physical exam, diagnostic test results, or other supporting documentation are missing or inadequate
Maintain legible, complete records and supply them upon request to reduce denial risk

Radiesse (calcium hydroxylapatite)FDA-approved injectable implant to restore or correct facial lipoatrophy in people with HIV (approved December 22, 2006)

Indication in policyBoth agents are considered reconstructive and medically necessary for treatment of facial defects due to HIV-associated facial lipoatrophy; cosmetic for other indications

Other FDA-cleared fillersPolicy notes FDA-approved injectable fillers (including poly-L-lactic acid and calcium hydroxylapatite microspheres) are used to treat HIV-associated facial lipoatrophy