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    v1.0.28
    OpenPayerPolicy UpdatesOtorhinolaryngology (ENT)UnitedHealthcare Dermal Filler Update | OpenPayer
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    CurrentUnitedHealthcarePolicy CS371NM.D

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

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

    Policy Summary
    PayerUnitedHealthcare
    PolicyInjectable Dermal Fillers and Bulking Agents (for New Mexico Only)
    Policy CodePolicy CS371NM.D
    Change TypeAdministrative update
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionEnsure the medical record fully supports medical necessity and includes relevant history, examination, and diagnostic results.
    SourceLink
    POLICY UPDATE CHANGES

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

    NMApplicable state
    2Covered dermal filler products
    3

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    CPT codes
    4HCPCS codes
    4Updated sections

    Coverage Criteria

    Dermal Filler Injections

    Covered when ALL of the following are met:

    Reconstructive dermal filler treatment for HIV-associated facial lipoatrophy

    • The individual is living with human immunodeficiency virus (HIV) infection.
    • The treatment addresses facial defects due to facial lipoatrophy.
    • The dermal filler product is Radiesse or Sculptra.

    Injectable Bulking Agents

    Covered when ALL of the following are met:

    Injectable bulking agent for vocal fold insufficiency or dysfunction

    • 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.

    Radiesse and Sculptra used for indications other than facial defects due to facial lipoatrophy in individuals living with HIV infection are considered cosmetic and not medically necessary.

    All dermal filler products other than Radiesse and Sculptra are considered cosmetic and not medically necessary.

    When Radiesse or Sculptra is used for an indication other than facial defects caused by HIV-associated facial lipoatrophy, the dermal filler treatment is not medically necessary.

    Use of dermal filler products other than Radiesse or Sculptra is considered not medically necessary.

    Coding

    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

    Provider Documentation and Action Items

    Documentation Required

    Medical Necessity Documentation Required

    Submit legible medical-record documentation that fully supports the medical necessity of the requested service. Documentation may be required for review but does not guarantee coverage; it must be maintained in the record and made available upon request.

    • Include the relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
    • Ensure the documentation supports the requested service and is legible and available upon request.
    Denial Risk

    Noncovered Dermal Filler Indication or Product

    Radiesse and Sculptra are considered reconstructive and medically necessary only for facial defects due to facial lipoatrophy in individuals living with HIV. These products are cosmetic and not medically necessary for all other indications, and all other dermal filler products are considered cosmetic and not medically necessary.

    Clinical Background

    HIV-associated facial lipoatrophy may develop during treatment with highly active antiretroviral therapy. The resulting facial fat loss can have substantial psychosocial effects, including effects on appearance and emotional well-being. Radiesse and Sculptra are FDA-approved fillers for facial fat loss associated with HIV.

    Definitions

    Vocal Cord Insufficiency
    ConditionOne or both vocal cords do not open correctly.
    Glottic closureThe glottis does not close properly, affecting alignment of the vocal folds.
    Associated symptomsVocal fatigue, poor voice quality or tone, and difficulty speaking, swallowing, or coughing may occur.
    Vocal Fold Insufficiency
    Also calledVocal cord dysfunction.
    Additional terminologyGlottal insufficiency.
    Related terminology in the document
    Policy Summary
    PayerUnitedHealthcare
    PolicyInjectable Dermal Fillers and Bulking Agents (for New Mexico Only)
    Policy CodePolicy CS371NM.D
    Change TypeAdministrative update
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionEnsure the medical record fully supports medical necessity and includes relevant history, examination, and diagnostic results.
    SourceLink
    On This Page
    Coverage CriteriaCodingProvider Documentation and Action ItemsClinical BackgroundDefinitions
    • Covered indication: facial defects due to facial lipoatrophy in an individual living with HIV.
    • Denial risk applies to Radiesse, Sculptra, or other dermal fillers used for noncovered indications or products.
    Denial Risk

    Bulking Agents Must Follow FDA Labeling

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

    • Use must comply with applicable FDA labeling requirements.
    • Denial risk applies when injectable bulking agents are used outside the FDA-labeled requirements or for conditions other than vocal fold insufficiency or dysfunction.
    Paradoxical vocal fold movement.