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Medical Policy Bulletin

Chemical Peels
11.08.08h

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 Policy Types and Descriptions section of this Medical Policy Web site.


Policy

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

MEDICALLY NECESSARY

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 Misspelled Wordimiquimod (Misspelled WordAldara) has been ineffective or contraindicated in treating the condition
NOT MEDICALLY NECESSARY

​The use of epidermal chemical peels for actinic keratoses and other premalignant skin lesions (e.g., actinic cheilitis, epidermodysplasia verruciformis) are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use.​

COSMETIC

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.

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, dermal 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 and the precertification requirements listed in this medical policy are met.

Subject to the terms and conditions of the applicable benefit contract, epidermal chemical peels for the treatment of actinic keratoses and other premalignant skin lesions are not eligible for payment under the medical benefits of the Company’s products because the service is considered not medically necessary and, therefore, not covered.

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, sometimes referred to as chemosurgery, chemexfoliation, and dermapeelingis the application of caustic material to the skin resulting in destruction of the epidermis and/or superficial dermis in whole or part. 

The three main classifications of chemical peels, characterized by the depth of the tissue injury caused, are superficial, medium, and deep. The depth of area of injury created by the peel is based on several factors including the type of chemical, the concentration of the chemical, number of applications, and the individual's skin type. 

Superficial chemical peels, sometimes referred to as epidermal peels, only penetrate the epidermis and therefore are used in indications affecting that layer (e.g., mild photoaging, melasma, and acne vulgaris). Common types of superficial peels are alpha hydroxy acids (AHAs), such as glycolic (30%–50%), lactic (10%–30%) or mandelic (40%); beta hydroxyl acids (BHAs), such as salicylic acid (30%); and alpha keto acids (AKAs), such as pyruvic acid (50%).​ 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.

Medium-depth peels, sometimes referred to as dermal peels, penetrate the epidermis and the papillary dermis and therefore are used in indications affecting those layers (e.g., moderate photoaging, mild acne scars, and actinic keratoses​). Common types of medium-depth peels are salicylic acid (>30%, multilayer application), glycolic acid (70%, with or without pretreatment primer such as Jessner’s solution), trichloroacetic acid (TCA) (30%–​50%, monolayer application, with or without pretreatment primer such as Jessner’s solution). Jessner’s solution is a primer used to optimize medium-depth peels by disrupting cornified layer (salicylic acid, 14g; resorcinol, 14g; lactic acid (85%), 14g; and ethanol to 100 mL). Chemical peels are appropriate when there are numerous lesions.

Deep peels, also sometimes referred to as dermal peels, penetrate the epidermis, papillary dermis, and midreticular dermis and therefore are used to treat indications affecting those layers (e.g., severe photoaging, deep acne scars, and premalignant skin neoplasms).​ Common types of deep chemical peels are TCA (>50%, monolayer application, with or without pretreatment primer such as Jessner’s solution), Baker-Gordon phenol peel (detergent, croton oil as an epidermolytic agent, phenol, and water for dilution to 50%–​55% phenol).

Actinic keratoses are keratinocyte neoplasms that occur on skin that has had long-term sun exposure. Actinic keratoses are typically confined to the epidermis but can extend into the papillary dermis or reticular dermis, where they are termed as squamous cell carcinomas. The estimated progression of actinic keratoses to squamous cell carcinomas varies from 0.1% to 20%. Typical treatment options include topical creams, gels, and solutions; cryosurgery; and photodynamic therapy. Lee et al. (2019) in the Journal of the American Academy of Dermatology list the indications for medium-depth peels and write that its “penetration into the papillary dermis supports its use in the treatment of actinic keratoses." ​

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 Septemeber 18, 2024.

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 Septemeber 18, 2024.

Berman B. Treatment of actinic keratosis. [UpToDate Web site]. 07/10/2024. Available at https://www.uptodate.c​om/contents/treatment-of-actinic-keratosis?search=actinic keratosis&topicRef=13712&source=see_link [via subscription only]. Accessed on Septemeber 18, 2024.

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 & 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 Septemeber 18, 2024.
Eisen DB, Asgari MM, Bennett DD, et al. Guidelines of care for the management of actinic keratosis. J Am Acad Dermatol. 2021;85(4):e209-e233. 

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

Lee KC, Wambier CG, Soon SL, et al. Basic chemical peeling: Superficial and medium-depth peels. J Am Acad Dermatol. 2019;81(2):313-324. 

Lynch SA, Schwarz KA. Chapter 83: Chemical Peeling and Dermabrasion. Plastic Surgery Secrets Plus. 2nd ed. Mosby. 2010:549-553. 

McIntyre WJ, Downs MR, Bedwell SA. Treatment options for actinic keratoses. Am Fam Physician. 2007;76(5):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://rarediseases.info.nih.gov/diseases/6357/epidermodysplasia-verruciformis​. Accessed on Septemeber 18, 2024.

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]. 01/08/2024. Available at https://www.uptodate.com/contents/epidemiology-natural-history-and-diagnosis-of-actinic-keratosis?search=actinic keratosis&source=search_result&selectedTitle=2~99&usage_type=default&display_rank=2 [via subscription only]. Accessed on Septemeber 18, 2024.

Reynolds RV, Yeung H, Cheng CE, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2024;90(5):1006.e1–1006.e30.​

Soleymani T, Lanoue J, Rahman Z. A Practical Approach to Chemical Peels: A Review of Fundamentals and Step-by-step Algorithmic Protocol for Treatment. J Clin Aesthet Dermatol. 2018;11(8):21-28.​

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-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)
THE FOLLOWING PROCEDURE CODES ARE MEDICALLY NECESSARY FOR ACTINIC KERATOSES AND OTHER PREMALIGNANT SKIN LESIONS:

15789, 15793

THE FOLLOWING PROCEDURE CODES ARE NOT MEDICALLY NECESSARY FOR ACTINIC KERATOSES AND OTHER PREMALIGNANT SKIN LESIONS:

15788, 15792​

ICD - 10 Procedure Code Number(s)
N/A

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

Cross Reference


Policy History

Revisions From 11.08.08h:
​10/02/2024
​​This policy has been reissued in accordance with the Company’s annual review process​.​
​11/01/2023
This policy has been reissued in accordance with the company’s annual review process​.
12/26​/2​022 This version of the policy will become effective 12/26/2022.

The Company’s coverage position has changed from Medically Necessary to Not Medically Necessary for the use of epidermal chemical peels to treat actinic keratoses and other premalignant skin lesions (e.g., actinic cheilitis, epidermodysplasia verruciformis), since reliable evidence and current clinical practices do not support it. 

Revisions From 11.08.08g:
09/08/2021 This policy has been reissued in accordance with the company’s annual review process
​​11/18/2020

​The policy has been reviewed and reissued to communicate the Company's continuing position on Chemical Peels.
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.

Effective 10/05/2017 this policy has been updated to the new policy template format.
12/26/2022
12/26/2022
10/02/2024
11.08.08
Medical Policy Bulletin
Commercial
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