CurrentUnitedHealthcarePolicy CS371ID.C

Injectable Dermal Fillers and Bulking Agents (for Idaho Only)

Defines medical necessity criteria for injectable dermal fillers and bulking agents for UnitedHealthcare members in Idaho, including Idaho Medicaid Plus; specifies covered indications (HIV-related facial lipoatrophy for Radiesse and Sculptra; FDA-labeled vocal fold medialization for bulking agents), noncovered cosmetic uses, applicable codes, and documentation expectations.

Policy Summary

PayerUnitedHealthcare

PolicyInjectable Dermal Fillers and Bulking Agents (for Idaho Only)

Policy CodePolicy CS371ID.C

Change TypeCodes added (Applicable Codes)

Effective DateMay 1, 2026

Next Review Date

Key ActionEnsure the patient medical record contains documentation supporting medical necessity including relevant history, exam, and diagnostic test results; make documentation available upon request.

SourceLink

POLICY UPDATE CHANGES

Added CPT codes 31570, 31571, and 31574 to Applicable Codes.

2Dermal fillers considered reconstructive (Radiesse, Sculptra)

all othersOther dermal fillers - cosmetic/not covered

1Covered bulking agent indication (vocal fold insufficiency per FDA)

3CPT procedure codes listed for vocal injection

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Coverage Summary

Scope: Injectable dermal fillers and injectable bulking agents for UnitedHealthcare members in Idaho (including Idaho Medicaid Plus). Policy Number: CS371ID.C. Status: CURRENT (effective May 1, 2026).

Coverage stance (concise): Mixed — Radiesse and Sculptra are covered (reconstructive/medically necessary) when used to correct facial defects due to HIV-associated facial lipoatrophy; injectable bulking agents are covered for treatment of vocal fold insufficiency when used according to FDA-labeled indications. Other dermal filler products and use of Radiesse/Sculptra for non–HIV-related cosmetic indications are not covered.

Key summary

Dermal fillers considered reconstructive (Radiesse, Sculptra)2

Other dermal fillers - cosmetic/not coveredall others

Covered bulking agent indication (vocal fold insufficiency per FDA)1

CPT procedure codes listed for vocal injection3

Effective date2026-05-01

Has material change recordedtrue

Dermal Filler Injections (Radiesse and Sculptra)

Dermal Filler Injections - Medically Necessary

Covered when ALL of the following are met:

ALL of the following

Product is Radiesse or Sculptra
Indication is treatment of facial defects due to facial lipoatrophy in individuals living with human immunodeficiency virus (HIV) infection

Dermal Filler Injections - Not Medically Necessary / Cosmetic

Not covered for the following:

ANY of the following

Use of Radiesse or Sculptra for all indications other than HIV-related facial lipoatrophy (cosmetic and not medically necessary)

Injectable Bulking Agents (Vocal Fold Medialization)

Injectable Bulking Agents - Medically Necessary

Covered when ALL of the following are met:

ALL of the following

Used for treatment of vocal fold insufficiency/dysfunction
Used according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions

Injectable Bulking Agents - Contraindications (from ALA guideline)

Contraindications (per ALA) to consider prior to injection:

ANY of the following

Unstable cardiopulmonary status

Applicable Codes

Vocal cord injection CPT (procedure) codes addedCPTCovered

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

Dermal filler injection for HIV-related lipodystrophy (HCPCS)HCPCSCovered

G0429

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

Injectable bulking agent supply codesHCPCSCovered

L8607

Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies

Product-specific drug J-codes / HCPCSHCPCSCovered

Q2026	Injection, Radiesse, 0.1ml
Q2028	Injection, sculptra, 0.5 mg

Provider Actions & Prior Authorization

Prior Authorization

Coverage limited by indication and product

Prior authorization or coverage determination should confirm that the product and indication meet policy limits: Radiesse or Sculptra for HIV-associated facial lipoatrophy, or injectable bulking agent use for vocal fold insufficiency per FDA labeling. Benefit coverage is determined by federal, state, or contractual requirements.

Affected codes: G0429, Q2026, Q2028, L8607, 31570, 31571, 31574
PA/coverage determination should confirm indication per brief

Documentation Required

Medical record documentation requirement

The patient's medical record must contain documentation that fully supports medical necessity for the requested services. Required documentation includes relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures. Documentation must be legible, maintained in the patient's medical record, and made available upon request for review.

Background & Evidence

Background: HIV-associated facial lipoatrophy (FLA) is a recognized complication of highly active antiretroviral therapy (HAART) that can result in significant facial fat loss, negative psychosocial effects, and reduced adherence to care. The FDA has approved injectable fillers for treatment of facial lipoatrophy in people with HIV, specifically Sculptra (poly-L-lactic acid) and Radiesse (calcium hydroxylapatite/carboxymethylcellulose).

Vocal fold insufficiency: A condition in which one or both vocal cords fail to close properly, causing voice and swallowing difficulties and increased risk of aspiration. Treatment options include voice therapy, thyroplasty, or vocal fold injection with FDA-cleared injectable bulking agents for medialization when used per labeled indications, contraindications, warnings, and precautions.

Citation	Key Findings
Vallejo et al. 2018	147 patients; objective improvement in 53% with dermal fillers; improved patient satisfaction
Jagdeo et al. 2015 systematic review	PLLA (Sculptra) assigned B-level recommendation; CaHA (Radiesse) assigned C-level recommendation for HIV FLA
Carroll & Rosen 2011	Average length of benefit for CaHA vocal fold injection 18.6 months

Facial lipoatrophy (FLA): Loss of facial subcutaneous fat, often associated with HIV and HAART, causing facial defects and psychosocial impact.

Vocal fold insufficiency: Condition where one or both vocal cords do not close properly, leading to voice changes, vocal fatigue, and potential swallowing/aspiration risk. Injectable bulking agents (vocal fold injections) augment the affected fold to improve glottic closure.

Revision History

05/01/2026Revision

Added CPT codes 31570, 31571, and 31574 to Applicable Codes.