Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Chemical Peels
Policy #:MA11.103a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

When performed as a cosmetic service, epidermal/dermal chemical peels for conditions including, but not limited to, wrinkles and photoaged skin are not covered by the Company because cosmetic services are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

However, epidermal/dermal chemical peels for actinic keratoses and other premalignant skin lesions (e.g., actinic cheilitis, epidermodysplasia verruciformis) are considered medically necessary and, therefore, covered when both of the following criteria are met:
  • More than 10 lesions
  • Topical 5-fluorouracil (5-FU) or imiquimod (Aldara) has been ineffective or contraindicated in treating the condition

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.

All requests for chemical peels require review by the Company and must include the following:
  • Photographs
  • Letter of medical necessity from the professional provider


Policy Guidelines

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, chemical peels are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Services that are cosmetic are excluded for the Company’s Medicare Advantage products because they are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

Description

A chemical peel (chemexfoliation) is the application of caustic material to the skin resulting in destruction of the epidermis and/or superficial dermis in whole or part. By applying chemical solutions such as trichloroacetic acid (TCA) or phenol, the amount of layers removed from the epidermis or superficial dermis can be controlled. Chemical peels are most commonly used to treat photoaged skin (e.g., wrinkles, solar elastosis) and to correct pigmentation abnormalities. They are less commonly used to treat multiple actinic and other keratoses and acne scars. They are used even less frequently to treat acne lesions.

Chemical peels can be used for both the epidermal and dermal layers. A chemical peel that affects the epidermal layer is called an epidermal peel. This application is commonly used to treat fine or subtle lines, lighten skin due to hyperpigmentary disorders, and improve the skin's texture and appearance.

A chemical peel that affects the dermal layer is called a dermal peel. This application is commonly used to treat some premalignant lesions, such as, but not limited to, actinic keratosis (considered a precursor of squamous cell carcinoma), actinic cheilitis (a condition that is similar to actinic keratosis but occurs on the vermilion of the lips), and epidermodysplasia verruciformis (an uncommon autosomal recessive disorder that predisposes individuals to the development of squamous cell carcinoma). Chemical peels are appropriate when there are numerous lesions. Additionally, dermal peels can be used to treat actinic damage, deep wrinkles, and acne scarring.

The American Academy of Dermatology (AAD) has noted that a review of the published, peer-reviewed scientific literature yields insufficient evidence to support the use of any type of chemical peel in the treatment of active acne vulgaris. The efficacy of chemical peels for the treatment of acne vulgaris is unproven due to the absence of randomized controlled studies that compare chemical peels with standard treatments.

Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function.
References

American Society of Plastic Surgeons (ASPS). Chemical peel. [ASPS Web site]. Available at:http://www.plasticsurgery.org/cosmetic-procedures/chemical-peel.html Accessed September 10, 2019.

American Academy of Oral Medicine (AAOM). Solar cheilitis. [AAOM Web site]. 01/24/2008. Available at: https://maaom.memberclicks.net/index.php?option=com_content&view=article&id=137:solar-cheilitis&catid=22:patient-condition-information&Itemid=120 . Accessed September 10, 2019.

Brodland DG, Roenigk RK. Trichloroacetic acid chemexfoliation (chemical peel) for extensive premalignant actinic damage of the face and scalp. Mayo Clin Proc. 1988;63(9):887-896.

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). 250.4: Treatment of actinic keratosis (AKs). [CMS Web site]. 11/26/01. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=129&ncdver=1&NCAId=1&ver=20&NcaName=Actinic+Keratoses&bc=gEAAAAAAEAAA& Accessed September 10, 2019.

Gold MH, Nestor MS. Current treatments of actinic keratosis. J Drugs Dermatol. 2006;5(2 Suppl):17-25.

Jorizzo J. Treatment of actinic keratosis. [UpToDate Web site]. 05/21/2019. Available at https://www.uptodate.com/contents/treatment-of-actinic-keratosis?search=actinic%20keratosis&topicRef=13712&source=see_link [via subscription only]. Accessed on September 10, 2019.

McIntyre, William J., Michael R. Downs, and Sondra A. Bedwell. Treatment options for actinic keratoses. Am Fam Physician76.5 (2007): 667-671.

Morganroth GS, Leffell DJ. Nonexcisional treatment of benign and premalignant cutaneous lesions. Clin Plast Surg. 1993;20(1):91-104.

National Institutes of Health Genetic and Rare Diseases Information Center. Epidermodysplasia verruciformis. 02/04/2010. Available at: https://maaom.memberclicks.net/index.php?option=com_content&view=article&id=137:solar-cheilitis&catid=22:patient-condition-information&Itemid=120 . Accessed on September 10, 2019.

Nelson BR, Fader DJ, Gillard M, et al. Pilot histologic and ultrastructural study of the effects of medium-depth chemical facial peels on dermal collagen in patients with actinically damaged skin. J Am Acad Dermatol. 1995;32(3):472-478.

Padilla RS. Epidemiology, natural history, and diagnosis of actinic keratosis. [UpToDate Web site]. 07/29/2019. Available at https://www.uptodate.com/contents/epidemiology-natural-history-and-diagnosis-of-actinic-keratosis?search=actinic%20keratosis&source=search_result&selectedTitle=2~99&usage_type=default&display_rank=2 [via subscription only]. Accessed on September 10, 2019.

Strauss JS, Krowchuk DP, Leyden JJ, et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol. 2007;56(4):651-663.

Taub AF. Procedural treatments for acne vulgaris. Dermatol Surg. 2007;33(9):1005-1026.

Van Scott EJ, Yu RJ. Alpha hydroxy acids: procedures for use in clinical practice. Cutis. 1989;43(3):222-228.

Witheiler DD, Lawrence N, Cox SE, et al. Long-term efficacy and safety of Jessner's solution and 35% trichloroacetic acid vs 5% fluorouracil in the treatment of widespread facial actinic keratoses. Dermatol Surg. 1997;23(3):191-196.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

15788, 15789, 15792, 15793


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

B07.8 Other viral warts

L56.8 Other specified acute skin changes due to ultraviolet radiation

L57.0 Actinic keratosis

L57.9 Skin changes due to chronic exposure to nonionizing radiation, unspecified



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

Revisions from MA11.103a
09/25/2019The policy has been reviewed and reissued to communicate the Company’s continuing position on Chemical Peels.
08/29/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Chemical Peels.
06/07/2017This policy has been reissued in accordance with the Company's annual review process.
08/17/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on Chemical Peels.
12/16/2015This policy will become effective on 12/16/2015.

This policy has been reviewed and updated to communicate the Company's continued position on chemical peels.


Revisions from MA11.103
04/01/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on Chemical Peels.
01/01/2015This is a new policy.





Version Effective Date: 12/16/2015
Version Issued Date: 12/16/2015
Version Reissued Date: 09/25/2019