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    v1.0.28
    OpenPayerPolicy UpdatesOtorhinolaryngology (ENT)UnitedHealthcare Injectable Coverage Update | Open…
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    CurrentUnitedHealthcarePolicy CS371KS.03

    Injectable Dermal Fillers and Bulking Agents (for Kansas Only)

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    This Kansas Medicaid managed care policy governs coverage of injectable dermal fillers for HIV-associated facial lipoatrophy and injectable bulking agents for vocal fold insufficiency or dysfunction. It applies only to services provided in Kansas.

    Policy Summary
    PayerUnitedHealthcare
    PolicyInjectable Dermal Fillers and Bulking Agents (for Kansas Only)
    Policy CodePolicy CS371KS.03
    Change TypeAdministrative updateno material clinical or coverage changes
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionMaintain legible medical record documentation supporting medical necessity and provide it upon request.
    SourceLink
    POLICY UPDATE CHANGES

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

    The previous policy version CS371KS.02 was archived.

    Kansas onlyGeographic applicability
    2Covered 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.

    CosmeticOther dermal filler use
    FDA-labeledBulking agent requirement
    7Listed procedure codes

    Medical Necessity and Coverage Criteria

    Radiesse or Sculptra for HIV-Associated Facial Lipoatrophy

    Radiesse or Sculptra are considered reconstructive and medically necessary when ALL of the following are met:

    ALL of the following

    • The individual is living with human immunodeficiency virus (HIV) infection.
    • The treatment is for facial defects due to facial lipoatrophy.

    Injectable Bulking Agents for Vocal Fold Insufficiency

    Injectable bulking agents are proven and medically necessary when ALL of the following are met:

    ALL of the following

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

    Other Dermal Filler Indications and Products

    The following indications and products are considered cosmetic and not medically necessary:

    ANY of the following

    • Radiesse or Sculptra is used for an indication other than facial defects due to facial lipoatrophy in an individual living with HIV infection.
    • Any other dermal filler product is used.

    Radiesse and Sculptra are considered cosmetic and not medically necessary for indications other than facial defects due to facial lipoatrophy.

    All other dermal filler products are considered cosmetic and excluded as not medically necessary.

    Radiesse or Sculptra used for indications other than HIV-associated facial lipoatrophy is cosmetic and not medically necessary.

    Use of all other dermal filler products is cosmetic and not medically necessary.

    Applicable Procedure and Supply Codes

    CPT CodesCPT
    31570Laryngoscopy, direct, with injection into vocal cord(s), therapeutic.
    31571Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or telescope.
    31574Laryngoscopy, flexible; with injection(s) for augmentation (eg, 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 Request Review Guidance

    Documentation Required

    Medical Necessity Documentation

    Submit legible medical record documentation that fully supports the medical necessity of the requested service. Include relevant medical history and physical examination findings, along with pertinent diagnostic test or procedure results when applicable.

    • Documentation must be maintained in the patient's medical record and made available upon request.
    • Medical record documentation may be required to assess coverage criteria but does not guarantee coverage.
    Denial Risk

    Cosmetic or Non-HIV Dermal Filler Indication

    Requests for Radiesse or Sculptra are considered cosmetic and not medically necessary when the indication is not facial lipoatrophy associated with HIV infection.

    • Radiesse and Sculptra may be considered reconstructive and medically necessary only for facial defects due to facial lipoatrophy in individuals living with HIV.

    Clinical Background

    HIV-associated facial lipoatrophy is facial fat loss that may occur in individuals receiving highly active antiretroviral therapy. It can adversely affect appearance and quality of life.

    Key Terms

    Vocal Fold Insufficiency
    DefinitionVocal fold insufficiency, also called vocal cord dysfunction or glottal insufficiency, occurs when one or both vocal cords do not open correctly.
    MechanismThe condition involves inadequate closure of the glottis, preventing the vocal folds from closing properly.
    Associated symptomsSymptoms may include vocal fatigue, poor voice quality or tone, and difficulty speaking, swallowing, or coughing.
    Vocal Fold Injection
    DefinitionVocal fold injection is a procedure in which a bulking agent is injected into the affected vocal fold.
    PurposeThe bulking agent helps the affected vocal fold sufficiently align with the opposing fold.
    Policy Summary
    PayerUnitedHealthcare
    PolicyInjectable Dermal Fillers and Bulking Agents (for Kansas Only)
    Policy CodePolicy CS371KS.03
    Change TypeAdministrative updateno material clinical or coverage changes
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionMaintain legible medical record documentation supporting medical necessity and provide it upon request.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaApplicable Procedure and Supply CodesDocumentation and Request Review GuidanceClinical BackgroundKey Terms
  1. All other dermal filler products are considered cosmetic and not medically necessary.
    2. Denial Risk

    Follow FDA Labeling

    Injectable bulking agents for vocal fold insufficiency or dysfunction must be used according to applicable U.S. Food and Drug Administration (FDA)-labeled indications, contraindications, warnings, and precautions.

    • Failure to follow FDA labeling may result in the request not meeting coverage requirements.
    Denial Risk

    Insufficient Medical Record Support

    Requests may be denied when medical record support is insufficient, illegible, unavailable upon request, or does not fully support the medical necessity of the requested services.

    • Include relevant history, physical examination findings, and pertinent diagnostic test or procedure results as applicable.
    Clinical useVocal fold injection is a treatment option for vocal fold insufficiency, along with voice therapy and thyroplasty.
    HIV-Associated Facial Lipoatrophy
    DefinitionHIV-associated facial lipoatrophy is facial fat loss associated with HIV infection.
    Radiesse FDA contextOn December 22, 2006, the FDA approved Radiesse to restore or correct signs of facial lipoatrophy or fat loss in people with HIV.
    Sculptra FDA contextOn August 3, 2004, the FDA approved Sculptra, an injectable form of poly-L-lactic acid, to correct facial fat loss in people with HIV.