L8607, Injectable bulking agent for vocal cord medialization, 0.1 ml, includes
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- 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.
- For facial lipodystrophy syndrome: photographic documentation of facial lipodystrophy syndrome caused by antiretroviral therapy in HIV-infected persons.
- For vocal cord paralysis: documentation of unilateral vocal cord paralysis (clinical findings supporting diagnosis) when requesting laryngeal injection with indicated materials (e.g., calcium hydroxylapatite, autologous fat, FDA-approved bulking agents).
Key Coverage Criteria
- Radiesse and Sculptra dermal fillers are medically necessary for treating facial defects caused by HIV-associated facial lipoatrophy.
- 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.
- Injectable fillers approved by the Food and Drug Administration (FDA) (e.g., Sculptra or Radiesse) are considered medically necessary for the treatment of photographically documented facial lipodystrophy syndrome caused by antiretroviral therapy in HIV-infected persons.
- Codes listed as 'Considered Medically Necessary' in the Coding Information when the applicable policy statements/criteria above are met (examples provided in policy): CPT 15773, 31513, 31570, 31571, 31573, 31574; HCPCS C1878, J3590, L8607, Q2026 for vocal cord medialization; CPT 15769, 15773 for velopharyngeal insufficiency; HCPCS G0429, Q2026, Q2028 for facial lipodystrophy syndrome.
- Treatment of a disease or congenital defect (for example, for breast contouring following breast reconstruction procedures).
11 Active Policies
ANTHEM-CG-SURG-123, CG-SURG-123 Autologous Fat Grafting and Injectable Soft Tissue Fillers
ANTHEM-MED.00132, MED.00132 Autologous Adipose-derived Regenerative Cell Therapy
UHC-POL-injectables-reconstructive-procedures, Injectable Dermal Fillers and Bulking Agents
CIGNA-0511, Injectable Fillers for Head and Neck Conditions
SUR716.001, Cosmetic and Reconstructive Procedures
Related Codes
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