Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Chemical Peels

Policy #:11.08.08g

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

When performed as a cosmetic service, epidermal/dermal chemical peels for conditions including, but not limited to, wrinkles, and photoaged skin are a benefit contract exclusion for all products of the Company and 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

Services performed due to recent trauma and/or accident and intended to restore a member to a pre-trauma and/or pre-accident state may be eligible for coverage, except when a specific benefit contract exclusion exists.

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

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, chemical peels for the treatment of actinic keratoses and other premalignant skin lesions are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

Services that are cosmetic are a benefit contract exclusion for all products of the Company. 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.

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.

Services performed due to recent trauma and/or accident and intended to restore a member to a pre-trauma and/or pre-accident state may be eligible for coverage, except when a specific benefit contract exclusion exists.
References


American Society of Plastic Surgeons (ASPS). Chemical peel. [ASPS Web site]. Available at:http://www.plasticsurgery.org/cosmetic-procedures/chemical-peel.html Accessed August 7, 2018.

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 August 7, 2018.

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

McIntyre, William J., Michael R. Downs, and Sondra A. Bedwell. Treatment options for actinic keratoses. Am Fam Physician 76.5 (2007): 667-671.

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

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.

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


Cross References


Policy History

Revisions to 11.08.08g
08/29/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Chemical Peels.

Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 12/16/2015
Version Issued Date: 12/16/2015
Version Reissued Date: 08/29/2018

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