CG-SURG-123 Autologous Fat Grafting and Injectable Soft Tissue Fillers

Anthem CG-SURG-123 addresses autologous fat grafting (fat transfer) and injectable soft-tissue fillers (e.g., PLLA, calcium hydroxylapatite, hyaluronic acid, collagen). Autologous fat grafting is covered as medically necessary when there is documented significant functional impairment and the procedure is expected to improve it, and it may be considered reconstructive to correct a significant deviation from normal anatomy (including after accidental injury); it is not covered when performed for cosmetic reasons, when no functional impairment exists, or when not reconstructive/only alters normal appearance. Coverage requires documentation of the impairment and anticipated functional improvement; separate criteria apply to injectable fillers as outlined in the policy.

"Autologous fat grafting is consideredmedically necessarywhen both of the following criteria have been met:"