Does Q2028 require prior authorization?

Yes, Q2028 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for Q2028?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`Q2028`, Injection, sculptra, 0.5 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

All documentation must be maintained in the patient's medical record, legible, include patient identifiers (e.g., full name, dates of service), and contain the legible signature of the responsible physician or non-physician practitioner to support medical necessity.

Use diagnosis code Z41.1 (Encounter for cosmetic surgery) for cosmetic procedures and apply GY modifier for statutorily excluded or non-covered services when submitting for denial; include condition code 21 for no-payment non-covered claims as appropriate.

For breast reduction, document height, weight, Body Surface Area (BSA), clinical evaluation of macromastia signs/symptoms, prior therapies and responses, operative report with weight removed from each breast, and pathology report with weight from each breast.

For gynecomastia, document glandular breast tissue on exam and/or mammography, persistence despite correction of underlying causes, ASPS Grade III or IV classification, exclusion of hormonal causes by labs (TSH, estradiol, prolactin, testosterone, LH), and persistence after 6 months of unsuccessful medical treatment and at least 1 year duration.

Key Coverage Criteria

Reconstructive surgery is covered for abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease when performed to improve function or approximate normal appearance.
Removal of breast implant(s) is covered when the medical record documents a condition that makes removal medically reasonable and necessary.
Breast reduction (reduction mammoplasty) is covered when clinical evaluation documents macromastia with signs/symptoms, height/weight and BSA are recorded, and back/neck/shoulder pain is unrelieved by at least 6 months of conservative treatment, with operative and pathology reports documenting the weight of tissue removed from each breast.
Mastectomy for gynecomastia is covered when glandular breast tissue consistent with true gynecomastia is documented, Grade III or IV classification (ASPS) is present, hormonal causes have been excluded by appropriate labs, medical treatment has failed for at least 6 months, and gynecomastia has persisted for at least 1 year.
Rhinoplasty is covered when medical record documents a condition requiring the procedure (including chronic nasal obstruction) with documentation of the cause of obstruction, appropriate diagnostic exams (e.g., anterior rhinoscopy, endoscopy, Cottle maneuver, CT) and prior conservative treatments with duration; septoplasty documentation must include surgical/pathology report when postoperative.
Rhinoplasty/Septoplasty to correct septal deformity that interferes with effective CPAP use is covered when medical management and duration of conservative therapy are documented showing interference with CPAP for treatment of an obstructive sleep disorder.

20 Active Policies

CGS-J15-L39506, Cosmetic and Reconstructive Surgery

J15

CGS-J18-L39506, Cosmetic and Reconstructive Surgery

J18

WPS-J5-L39051, Cosmetic and Reconstructive Surgery

A58774, Billing and Coding: Cosmetic and Reconstructive Surgery

WPS-J8-L39051, Cosmetic and Reconstructive Surgery

EVICORE-HPLAN-CIGNA-FFF78083B324, Cigna Commercial Other Services Code List - Effective 03/07/2026

A59299, Billing and Coding: Cosmetic and Reconstructive Surgery

UHC-POL-injectables-reconstructive-procedures, Injectable Dermal Fillers and Bulking Agents

CIGNA-0511, Injectable Fillers for Head and Neck Conditions

AMBETTER-CP.MP.31, Cosmetic and Reconstructive Procedures

BCBSIL-SUR716.001, Cosmetic and Reconstructive Procedures

BCBSMT-SUR716.001, Cosmetic and Reconstructive Procedures

BCBSNM-SUR716.001, Cosmetic and Reconstructive Procedures

BCBSOK-SUR716.001, Cosmetic and Reconstructive Procedures

UMR-POL-UMR-injectables-reconstructive-procedures, Injectable Dermal Fillers and Bulking Agents

SUREST-POL-SUREST-injectables-reconstructive-procedures, Injectable Dermal Fillers and Bulking Agents

ANTHEM-MP-A050278, Last Review Date

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

ANTHEM-MED.00132, Autologous Adipose-derived Regenerative Cell Therapy

EVICORE-HPLAN-CIGNA-AFCE721BA4F3, Cigna Comprehensive Code List - Effective 03/07/2026

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Q2028, Injection, sculptra, 0.5 mg