31574
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
2.37
Facility
$129.26
Non-Facility
$901.82
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the guidelines titled Medical Records Documentation Used for Reviews.
- When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs.
- For velopharyngeal insufficiency treated with autologous fat injection, documentation that ALL the following criteria are met: History of hypernasal speech; History of nasal regurgitation of food or liquid; Naso-endoscopic evidence of a functional velopharyngeal insufficiency; A speech evaluation by a speech-language pathologist documenting functional impairment not correctable by speech therapy alone.
Key Coverage Criteria
- Radiesse and Sculptra are considered reconstructive and medically necessary for the treatment of facial defects due to facial lipoatrophy in individuals living with human immunodeficiency virus (HIV) infection.
- Injectable bulking agents are proven and medically necessary for the treatment of vocal fold insufficiency/ dysfunction when used according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions.
- HCPCS G0429: Dermal Filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy) (listed in Applicable Codes as the code describing the covered service for facial lipodystrophy).
- Vocal fold injection (augmentation/medialization) using FDA-cleared bulking agents for glottal insufficiency (indications described in clinical sections and practice guidelines, e.g., unilateral vocal fold paralysis or paresis, vocal fold atrophy, vocal fold scar, sulcus vocalis, or loss of the soft tissue of the vocal folds per ALA guidance).
- Laryngeal injection of ANY of the following is considered medically necessary for the treatment of unilateral vocal cord paralysis: calcium hydroxylapatite (e.g., Radiesse Voice, Prolaryn Plus), autologous fat, bulking agents specifically approved by the U.S. Food and Drug Administration (FDA) for the treatment of unilateral vocal cord paralysis.
- Autologous fat injection is considered medically necessary for the treatment of velopharyngeal insufficiency when ALL the following criteria are met: History of hypernasal speech; History of nasal regurgitation of food or liquid; Naso-endoscopic evidence of a functional velopharyngeal insufficiency; A speech evaluation, conducted by a speech-language pathologist, which documents the functional impairment that cannot be corrected by speech therapy alone.
11 Active Policies
UHC-POL-injectables-reconstructive-procedures — Injectable Dermal Fillers and Bulking Agents
UMR-POL-UMR-injectables-reconstructive-procedures — Injectable Dermal Fillers and Bulking Agents
SUREST-POL-SUREST-injectables-reconstructive-procedures — Injectable Dermal Fillers and Bulking Agents
CIGNA-0511 — Injectable Fillers for Head and Neck Conditions - (0511)
Related Codes
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