CurrentUnitedHealthcarePolicy CS371NMB

Injectable Dermal Fillers and Bulking Agents (for New Mexico Only)

Policy governing coverage of dermal filler injections and injectable bulking agents for members in New Mexico, including indications for HIV-related facial lipoatrophy and vocal fold insufficiency, and specifying cosmetic vs reconstructive determinations.

Policy Summary

PayerUnitedHealthcare

PolicyInjectable Dermal Fillers and Bulking Agents (for New Mexico Only)

Policy CodePolicy CS371NMB

Change TypeMaterial revisions clarifying product-specific coverage and FDA-label alignment

Effective DateDec 1, 2024

Next Review Date

Key ActionSubmit prior authorization with appropriate procedure/product codes and clinical justification aligned with covered indications (HIV facial lipoatrophy for Sculptra/Radiesse; FDA-labeled vocal fold insufficiency for bulking agents).

SourceLink

POLICY UPDATE CHANGES

Revised language to indicate Radiesse and Sculptra are reconstructive and medically necessary for treatment of facial defects due to facial lipoatrophy in individuals with HIV; all other dermal fillers are cosmetic and not medically necessary.

Replaced previous language about specific injectable bulking agents (e.g., Prolaryn) with a general statement that injectable bulking agents are proven and medically necessary for vocal fold insufficiency when used according to FDA labeling.

Policy retitled to 'Injectable Dermal Fillers and Bulking Agents (for New Mexico Only)'.

50%estimated with significant facial lipoatrophy on HAART

18.6 moavg benefit duration (CaHA injections)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

64%loss of benefit in study

12/01/2024policy effective

Coverage Criteria

Dermal Filler Injections

Covered when ALL of the following are met:

HIV-related facial lipoatrophy indication: Patient has facial defects due to facial lipoatrophy associated with human immunodeficiency virus (HIV) infection

Policy specifies Radiesse and Sculptra as reconstructive and medically necessary for this indication.

Product: Use of Radiesse (calcium hydroxylapatite) or Sculptra (poly-L-lactic acid)

Other dermal filler products are considered cosmetic and not medically necessary.

Injectable Bulking Agents for Vocal Fold Insufficiency

Covered when ALL of the following are met:

Diagnosis: Patient has vocal fold insufficiency/dysfunction (e.g., unilateral vocal fold paralysis/paresis, vocal fold atrophy, vocal fold scar, sulcus vocalis) as supported by clinical evaluation

Clinical practice guidance recognizes these as indications for medialization.

Product use: Bulking agent is used according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions

Policy requires alignment with FDA labeling for covered use.

Radiesse and Sculptra are designated as reconstructive and medically necessary when used to treat facial defects caused by facial lipoatrophy in individuals living with human immunodeficiency virus (HIV). For all other indications, Radiesse and Sculptra are considered cosmetic and not medically necessary.

The use of dermal filler products other than Radiesse and Sculptra is considered cosmetic and not medically necessary for all indications other than HIV-related facial lipoatrophy. Requests for these other products for non–HIV-related indications are subject to denial as cosmetic care.

Coding

Referenced procedure codes for dermal fillersHCPCS

G0429

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

Referenced HCPCS/Q-codes for bulking agents and specific fillersHCPCS

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 & Billing Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for covered procedure and product codes. Providers must submit the appropriate procedure/product codes and clinical justification demonstrating the request aligns with the covered indications described in this policy.

Submit prior authorization with diagnosis, relevant history, and prior treatments
Include product HCPCS/Q-code and procedure code on request

Denial Risk

Bulking Agents & Indication Alignment

Bulking agents are considered medically necessary only when used in accordance with FDA-labeled indications, contraindications, warnings, and precautions. Use of injectable bulking agents outside FDA-labeled indications or inconsistent with labeling may be denied as not medically necessary.

Requests for bulking agents for indications not supported by FDA labeling or this policy may be denied

Definitions

inv-13: Facial lipoatrophy (HIV-associated) — definition and clinical impact

DefinitionLoss of facial subcutaneous fat in individuals with HIV, often associated with HAART, producing facial defects and significant psychosocial impact (negative social stigma, poor body image, body dysmorphic disorder).

Clinical significanceMay lead to nonadherence to HAART, missed infectious disease visits, and discontinuation of other medications due to severe body image disturbance.

FDA‑approved treatmentsPoly-L-lactic acid (Sculptra), calcium hydroxylapatite microspheres, and carboxymethylcellulose (Radiesse) are FDA‑approved injectable fillers for HIV‑related facial lipoatrophy.

Estimated prevalenceApproximately 50% of HIV patients treated with HAART develop significant facial lipoatrophy.

inv-14: Vocal fold insufficiency / glottal insufficiency — definition and clinical impact

Background

Facial lipoatrophy associated with HIV infection and antiretroviral therapy can produce loss of facial subcutaneous fat and significant psychosocial impact. FDA‑approved fillers such as Sculptra (poly‑L‑lactic acid) and Radiesse (calcium hydroxylapatite) are used to restore facial volume in this setting and are considered reconstructive and medically necessary for treating facial defects due to HIV‑related facial lipoatrophy. Other dermal filler products are not approved for this reconstructive indication and are considered cosmetic and not medically necessary when used for indications outside HIV‑related facial lipoatrophy.

Policy Summary

PayerUnitedHealthcare

PolicyInjectable Dermal Fillers and Bulking Agents (for New Mexico Only)

Policy CodePolicy CS371NMB

Change TypeMaterial revisions clarifying product-specific coverage and FDA-label alignment

Effective DateDec 1, 2024

Next Review Date

SourceLink

On This Page

Dermal fillers other than Radiesse or Sculptra for HIV-related facial lipoatrophy are considered cosmetic / not medically necessary

Documentation Required

Coding and Clinical Documentation

Claims and prior authorization requests must include accurate coding and supporting clinical documentation. Providers should document the clinical indication, prior conservative therapies (when applicable), and rationale for the selected product and procedure.

Include procedure and product codes on claims (e.g., G0429; L8607; Q2026; Q2028)
Attach clinical notes showing diagnosis, examination (including voice and vocal fold mobility when relevant), and treatment rationale
Provide documentation of counseling or consideration of alternatives when required

Note

Conservative Therapy Considerations Before Injection

Conservative therapy should be considered and documented prior to vocal fold injection medialization when clinically appropriate. Examples include voice therapy and other non-surgical rehabilitative measures. Vocal fold injection may be described as a temporary intervention to improve voice and potentially reduce need for later surgical reconstruction.

Document trials of voice therapy or other conservative management when applicable
If urgent or post-surgical vocal fold medialization is performed, document clinical rationale for immediate injection

DefinitionCondition in which one or both vocal cords do not close properly (vocal cord insufficiency/glottal insufficiency), sometimes termed vocal cord dysfunction or paradoxical vocal fold movement.

Key symptoms and risksLeads to vocal fatigue and increased risk of laryngeal penetration, aspiration, and pneumonia when the glottis does not close properly.

Common clinical causes/manifestationsIncludes unilateral vocal fold paralysis/paresis, vocal fold atrophy, vocal fold scar, and sulcus vocalis as etiologies of glottal insufficiency.

Treatment approachManagement options include conservative measures such as voice therapy, surgical thyroplasty, or vocal fold injection medialization using injectable bulking agents to improve glottic closure.