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Injectable Dermal Fillers for Cosmetic Procedures
05.00.62i

Policy

This policy does not address the use of injectable implants and materials similar to dermal fillers such as Prolaryn Plus®​ or Renú®​ Voice (calcium hydroxylapatite​) for ​​vocal cord medialization (treatment of unilateral vocal cord paralysis)​.​

COSMETIC
For most plans, Injectable dermal fillers, such as, but not limited to, the following, are not covered by the Company because they are considered a cosmetic service.​
  • calcium hydroxylapatite (Radiesse®​​)​​ 
  • autologous fat transfer, 
  • poly-L-lactic acid (Sculptra®), 
  • autologous cellular product (azficel-T, laVív), 
  • human collagen (CosmoDerm, CosmoPlast), 
  • hyaluronic acid (Restylane, Restylane L, Juvederm, Captique, Belotero Balance, Prevelle Silk, Hydrelle), 
  • modified hyaluronic acid from avian source (Hylan B Gel), bovine collagen (Zyplast, Zyderm), 
  • human collagen from human tissue (Cymetra), and 
  • polymethyl methacrylate [PMMA] microsphere-enhanced bovine collagen (Artefill) 
Services that are cosmetic are a benefit contract exclusion for most products of the Company. Therefore, they are not eligible for reimbursement consideration.

Services performed due to recent trauma and/or accident and intended to restore a member to a pre-trauma and/or pre-accident state may be eligible for coverage, except when a specific benefit contract exclusion exists.

​REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, injectable dermal fillers that do not meet the medical necessity criteria listed in this policy are considered cosmetic services. Services that are cosmetic are a benefit contract exclusion for most products of the company. Therefore, they are not eligible for reimbursement consideration.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The Center for Devices and Radiological Health (CDRH) of the FDA granted premarket approval for Sculptra® (injectable poly-L-lactic acid) on August 3, 2004, and for Radiesse® (calcium hydroxylapatite) on December 22, 2006, for the treatment of HIV-associated facial lipoatrophy. 

The FDA has also approved numerous other injectable dermal (wrinkle) filler, volume-producing agents localized to the face to smooth wrinkles and folds; correct contour deficiencies; and augment lips.

The FDA has not approved injectable dermal (wrinkle) filler, volume-producing agents to:
  • Augment (increase volume of) or alter the shape of facial features such as cheeks and nose
  • Increase breast size (breast augmentation)
  • Increase buttocks size
  • Rejuvenate feet
  • Implant into bone, tendon, ligament, or muscle

Description

Dermal fillers vary from biologic to synthetic materials, and from absorbable to nonabsorbable compounds. In general, dermal fillers are volume-producing agents that are approved for injection into the dermal layers for the correction of moderate-to-severe wrinkles, contour deficiencies, folds, depressions​, and to increase volume in the hands.

Dermal fillers include human fat and medical device implants approved for medical use by the Food and Drug Administration (FDA). Autologous fat transfer is the removal of fat from one part of the body and transferring it somewhere else on the body. The FDA has approved a multitude of injectable dermal fillers and volume-producing agents for treatment localized to the face in order to create a smoother appearance. The agents include, but are not limited to, autologous cellular product (azficel-T, laVív), human collagen (CosmoDerm, CosmoPlast), hyaluronic acid (Restylane, Restylane L, Juvederm, Captique, Belotero Balance, Prevelle Silk, Hydrelle), bovine collagen (Zyplast, Zyderm), human collagen from human tissue (Cymetra), microscopic plastic beads and polymethyl methacrylate [PMMA] microsphere-enhanced bovine collagen (Artefill), calcium hydroxylapatite [CaHA] (Radiesse®), and Poly-L-Lactic Acid (PLLA) (Sculptra Aesthetic). In addition, Restylane and Restylane L Injectable Gels are approved for lip augmentation in those over the age of 21 years.

The use of injectable dermal fillers has aesthetic applications. For example, these products provide volume for wrinkles around the eyes, cheeks, lips, and neck, thereby improving appearance. Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiological function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiological function.

References

Hanke CW, Rohrich RJ, Busso M, et al. Facial Soft-Tissue Fillers conference: Assessing the State of the Science. J Am Acad Dermatol. 2011;64(4 Suppl):S66-85.
​
US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Sculptra (injectable poly-L lactic acid). Premarket approval letter. [FDA Web site]. 08/03/04. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf3/P030050S002a.pdf. Accessed on January 21, 2026​.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Radiesse®. Summary of safety and effectiveness. [FDA Web site]. 12/22/06. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf5/P050037b.pdf. Accessed on January 21, 2026.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Radiesse®. Premarket approval letter. [FDA Web site]. 12/22/06. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf5/p050052a.pdf. Accessed on January 21, 2026.

US Food and Drug Administration (FDA) Cosmetic Devices. Dermal fillers approved by the Center for Devices and Radiological Health. [FDA Web site]. Available at: https://www.fda.gov/medical-devices/aesthetic-cosmetic-devices/fda-approved-dermal-fillers. Accessed on January 21, 2026.
​
US Food and Drug Administration (FDA) Medical Devices Advisory Committee, General and Plastic Surgery Devices Panel. Panel meeting summary, November 18-19, 2008. [FDA Web site]. Available at: https://wayback.archive-it.org/7993/20170405193134/https:/www.fda.gov/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/GeneralandPlasticSurgeryDevicesPanel/ucm125405.htm. Accessed on January 21, 2026.​

US Food and Drug Administration (FDA). Radiesse injectable implant: Instructions for use. [FDA Web site]. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf5/p050037c.pdf. Accessed on Accessed on January 21, 2026.​

Coding

CPT Procedure Code Number(s)
​11950, 11951, 11952, 11954
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)
G0429    Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy)​

Q2026    Injection, Radiesse, 0.1 ML

Q2028    Injection, Sculptra, 0.5 MG

Q4112    Cymetra, injectable, 1 cc​


THE FOLLOWING CODE REPRESENTS OTHER INJECTABLE DERMAL FILLERS AS COSMETIC SERVICES:

J3590     Unclassified Biologics
Revenue Code Number(s)
N/A


Coding and Billing Requirements

Policy History

Revisions From 05.00.62i:
​04/01/2026
​​This policy has been reissued in accordance with the Company's annual review process.​​
​05/28/2025
​This policy has been reissued in accordance with the Company's annual review process.​
​06/26/2024
​This policy has been reissued in accordance with the Company's annual review process.​

​07/01/2023

​This version of the policy will become effective 07/01/2023.

The title has been changed from "Injectable Dermal Fillers" to "Injectable Dermal Fillers for Cosmetic Procedures".​


Language was added to clarify that injectable implants such as Prolaryn Plus® or Renú®​ Voice​ (calcium​​ hydroxylapatite) and materials similar to dermal fillers for vocal cord medialization (treatment of unilateral vocal cord paralysis) are not addressed in this policy.​​​


The following policy criteria have been updated:

  • Language regarding Medical Necessity of Radiesse®​ for the treatment of unilateral vocal cord paralysis was removed as a result of the product no longer being marketed and instructed for use for that indication by the manufacturer and FDA. It is now only marketed and instructed for use as a product for moderate to severe lower face wrinkles and for volume loss in the hands, which are considered cosmetic services.
​The following code has been added to the policy:
  • Q4112    Cymetra, injectable, 1 cc​
​
Revisions From 05.00.62h:
​06/16/2021
​This policy has been reissued in accordance with the Company's annual review process.​
​​10/21/2020​
​The policy has been reviewed and reissued to communicate the Company's continuing position on injectable dermal fillers. 
06/05/2019The policy has been reviewed and reissued to communicate the Company’s continuing position on injectable dermal fillers.
10/10/2018This policy has been reissued in accordance with the Company's annual review process.

Effective 10/05/2017 this policy has been updated to the new policy template format.
7/1/2023
6/30/2023
4/1/2026
05.00.62
Medical Policy Bulletin
Commercial
No