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    v1.0.28
    OpenPayerPolicy UpdatesOtorhinolaryngology (ENT)UnitedHealthcare Dermal Filler Coverage | OpenPaye…
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    CurrentUnitedHealthcarePolicy CS371KY.04

    Injectable Dermal Fillers and Bulking Agents (for Kentucky Only)

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    This policy governs coverage of injectable dermal fillers and bulking agents for UnitedHealthcare Community Plan members in Kentucky. It addresses dermal fillers for HIV-associated facial lipoatrophy and injectable bulking agents for vocal fold insufficiency or dysfunction.

    Policy Summary
    PayerUnitedHealthcare
    PolicyInjectable Dermal Fillers and Bulking Agents (for Kentucky Only)
    Policy CodePolicy CS371KY.04
    Change TypeSupporting-information updatesno material clinical or coverage changes
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionEnsure the medical record fully supports medical necessity and includes relevant history, examination findings, and pertinent diagnostic results.
    SourceLink
    POLICY UPDATE CHANGES

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

    KentuckyApplicable state
    2 productsCovered dermal filler products for HIV-associated facial lipoatrophy

    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.

    Not covered
    Other dermal filler products
    3 CPT / 4 HCPCSListed procedure and supply codes
    5Updated policy sections

    Medical Necessity and Noncovered Services

    Dermal Fillers for HIV-Associated Facial Lipoatrophy

    Covered as reconstructive and medically necessary when ALL of the following are met:

    ALL of the following

    • ONE of the following products

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

    Injectable Bulking Agents for Vocal Fold Insufficiency or Dysfunction

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

    ALL of the following

    • The clinical indication is 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.

    Cosmetic and Non-Medically Necessary Dermal Filler Use

    The following uses are 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 used for indications other than facial defects due to facial lipoatrophy in individuals living with HIV are considered cosmetic or not medically necessary.

    FDA approval alone is not a basis for coverage.

    Dermal filler treatment with Radiesse or Sculptra for indications other than facial defects due to facial lipoatrophy in individuals living with HIV, and treatment with all other dermal fillers, is not medically necessary.

    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 (e.g., 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 Coverage Guardrails

    Documentation Required

    Medical Necessity Records Required

    Maintain complete medical-necessity records for every requested service. Documentation must fully support the requested treatment and be legible, maintained in the patient's medical record, and available upon request; documentation alone does not guarantee coverage.

    • Include relevant medical history.
    • Include physical examination findings.
    • Include results of pertinent diagnostic tests or procedures.
    • Include any other records supporting medical necessity.
    Denial Risk

    Cosmetic or Noncovered Dermal Filler Indication

    Coverage is limited to the policy-supported reconstructive indication for Radiesse and Sculptra. Use outside HIV-associated facial lipoatrophy, or use of any other dermal filler product, is considered cosmetic and not medically necessary and may be denied.

    Clinical Background

    HIV-associated facial lipoatrophy is facial fat loss that may lead to social stigma and body dysmorphic disorder. It may also reduce adherence to antiretroviral therapy.

    Relevant Clinical Terms

    Vocal Cord Insufficiency / Glottal Insufficiency
    DefinitionVocal cord insufficiency, also called vocal cord dysfunction or glottal insufficiency, occurs when one or both vocal cords do not open correctly.
    Incomplete glottic closureWhen the glottis does not close properly, vocal fatigue, poor voice quality or tone, and difficulty speaking, swallowing, or coughing may occur.
    Potential complicationsVocal fold insufficiency increases the risk of laryngeal penetration, aspiration, and pneumonia.
    Vocal Fold Injection Augmentation
    ProcedureVocal fold injection augmentation involves injecting a bulking agent into the affected vocal fold to help it align sufficiently with the opposing fold.
    Indication: paralysis or paresisIndicated for glottal insufficiency due to unilateral vocal fold paralysis or paresis.
    Policy Summary
    PayerUnitedHealthcare
    PolicyInjectable Dermal Fillers and Bulking Agents (for Kentucky Only)
    Policy CodePolicy CS371KY.04
    Change TypeSupporting-information updatesno material clinical or coverage changes
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionEnsure the medical record fully supports medical necessity and includes relevant history, examination findings, and pertinent diagnostic results.
    SourceLink
    On This Page
    Medical Necessity and Noncovered ServicesProcedure and Supply CodesDocumentation and Coverage GuardrailsClinical BackgroundRelevant Clinical Terms
    • Radiesse and Sculptra: covered only for facial defects due to facial lipoatrophy in individuals living with HIV infection.
    • All other indications for Radiesse and Sculptra are cosmetic and not medically necessary.
    • All other dermal filler products are considered cosmetic and not medically necessary.
    Denial Risk

    Bulking Agent Use Outside Policy Criteria

    Verify the indication and product requirements before billing injectable bulking agents. Coverage is limited to treatment of vocal fold insufficiency or dysfunction when the agent is used according to applicable FDA-labeled indications, contraindications, warnings, and precautions. Use outside these criteria may be denied.

    • Use only for vocal fold insufficiency or dysfunction.
    • Confirm compliance with FDA-labeled indications, contraindications, warnings, and precautions.
    • FDA approval or clearance alone is not a basis for coverage; applicable policy requirements and medical-necessity documentation must also be met.
    Indication: tissue abnormalitiesAlso indicated for glottal insufficiency due to vocal fold atrophy, vocal fold scar, sulcus vocalis, or loss of soft tissue of the vocal folds.