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MP 8.01.16 |
Chemical Peels |
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| Medical Policy | ||
| Section Therapy |
Original Policy Date 4/10/98 |
Last Review Status/Date Reviewed by consensus/3:2003 |
| Issue 3:2003 |
Return to Medical Policy Index |
Disclaimer
Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.
Description
A chemical peel refers to a controlled removal of varying layers of the epidermis and superficial dermis with the use of a “wounding” agent, such as phenol or trichloroacetic acid (TCA). The most common indication for chemical peeling is as a treatment of the photoaged skin, i.e., correcting pigmentation abnormalities, solar elastosis, and wrinkles. However, chemical peeling has also been used as a treatment for multiple actinic keratoses when treatment of individual lesions is not feasible, and for various stages of acne.
Chemical peels can be subdivided into the types of wounding agents used and the depth of the peel—either epidermal or dermal. However, the common mechanism of action is exfoliation of the skin, followed by re-epithelialization generating from the epithelial appendages and adnexal structures. The most common wounding agents are various preparations of phenol (i.e., Baker’s solution), trichloroacetic acid (TCA), Jessner’s solution, (i.e., resorcin, salacylic and lactic acid), and alpha hydroxy acids.
An epidermal peel may be used to remove fine, subtle lines, soften the appearance of enlarged pores, improve the skin texture, and lighten hyperpigmentary disorders. Multiple epidermal peels (also referred to as chemical exfoliation) may also be used as a comedolytic therapy in patients with active acne. (A prominent manifestation of acne is the open or closed comedo, which refers to a plug of keratin and sebum within the dilated hair follicle. Disruption of the follicular wall with exposure of the sebum and keratin to the dermis produces the characteristic inflammatory lesions of acne.)
Dermal peels may be used to treat deep wrinkling, actinic damage, or actinic keraotoses. Acne scarring has also been treated with dermal peels, but dermabrasion may be more effective in patients with deep scarring. After dermal peels, the treated areas will develop marked edema and erythema with a profuse exudate. Post-peel dryness and itching develop between 7 and 10 days. The erythema usually takes 6 to 8 weeks to resolve.
Policy
Epidermal chemical peels used to treat photoaged skin, wrinkles, or acne scarring is considered cosmetic.
Dermal chemical peels as a treatment of end-stage acne scarring is considered cosmetic.
Dermal chemical peels used to treat patients with numerous(>10) actinic keratoses or other premalignant skin lesions, such that treatment of the individual lesions becomes impractical, may be considered medically necessary.
Epidermal chemical peels used to treat patients with active acne that have failed a trial of topical and/or oral antibiotic acne therapy are considered medically necessary. In this setting superficial chemical peels with 50%–70% alpha hydroxy acids are used as a comedolytic therapy. (Alpha hydroxy acids can also be used in lower concentrations [8%] without the supervision of a physician.)
Policy Guidelines
Requests for all chemical peels should be carefully evaluated to determine whether their rationale is primarily cosmetic. Epidermal peels would only be considered medically necessary in patients with active acne who have failed other therapy. Dermal peels would be considered medically necessary only in patients with multiple actinic keratoses.
There are a variety of CPT codes that describe chemical peels. CPT codes 15788 and 15789 describe epidermal peels, for the facial and nonfacial areas, respectively. CPT codes 15792 and 15793 describe the corresponding dermal peels. A distinct CPT code, 17360, specifically describes chemical exfoliation for acne.
Benefit Application
BlueCard/National Account Issues
Specific contract language regarding the definitions of cosmetic services, particularly as applied to the treatment of active acne and acne scarring, may supersede this policy.
Chemical exfoliation (CPT code 17360) may be considered part of the general dermatology evaluation and management services and, therefore, Plans may consider whether to accept separate billing for chemical exfoliation as a treatment of acne.
Rationale
The main issue regarding chemical peels is the determination of whether the treatment is primarily cosmetic in nature. Actinic keratoses are premalignant lesions, and the medical necessity for their destruction/removal is considered appropriate, although watchful waiting may also be an option. However, a chemical peel for the treatment of actinic keratoses would only be appropriate when there are numerous lesions, making treatment of the individual lesions impractical. For example, Morganroth and Leffell suggest that patients with fewer than 10 actinic keratoses should be treated with cryotherapy. (1)
In addition, curative treatment of actinic keratoses requires a full-thickness necrosis of the epidermis. Brodland and Roenigk estimate that this depth of necrosis would be unlikely with concentrations of TCA less than 35%. (2) Therefore, requests for epidermal peels as a treatment of actinic keratoses may actually represent primarily cosmetic procedures and should be carefully evaluated.
Policy toward acne in general may vary from Plan to Plan, based on contractual language. Some Plans may consider active acne a disease and thus its treatment eligible for coverage, while the treatment of end-stage acne scarring may be considered cosmetic, since active disease is no longer present. The same policy can be applied to chemical peels. Those chemical peels designed to remove closed comedones as a method of minimizing inflammation and scarring may be considered medically necessary, while those peels designed to treat end-stage scars would be considered cosmetic. Making the distinction between active and inactive acne can be difficult. However, simultaneous treatment with either antibiotics or tretinoin is one indication that the patient has active ongoing disease.
Epidermal peels with alpha-hydroxy acids, so-called fruit acids that include glycolic acid and lactic acid, are frequently used for the treatment of active acne (CPT code 17360). While low concentrations of glycolic acid can be administered by the patient at home, higher concentrations (50%–70%) are administered in the dermatologist’s office. (3) Superficial glycolic acid peels are usually done as an adjunct to other comedolytic therapy done in the office. Typically, patients are treated every 2–3 weeks on a repeated basis. Since chemical peeling does not represent a curative therapy, treatments may be continued over the course of years. Superficial peels for these patients represent a more intense form of therapy, inasmuch as referral to a dermatologist is required. Therefore patients with acne requesting coverage for chemical peels should have failed a trial of topical and oral antibiotic therapy for acne.
References:
- Morganroth GS, Leffell DJ. Nonexcisional treatment of benign and premalignant cutaneous lesions. Clin Plast Surg 1993; 20(1):91-104.
- 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):887-96.
- Van Scott EJ, Yu RJ. Alpha hydroxy acids: Procedures for use in clinical practice. Cutis 1989; 43(3):222-8.
Source:
A search of the literature was completed through the MEDLINE database for the period of January 1992 through January of 1998. The search strategy focused on references containing the following words:
Chemical peel
Chemical exfoliation
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Codes |
Number |
Description |
| CPT | 15788 | Chemical peel, facial, epidermal |
| 15789 | Chemical peel, facial, dermal | |
| 15792 | Chemical peel, nonfacial epidermal | |
| 15793 | Chemical peel, nonfacial, dermal | |
| 17360 | Chemical exfoliation for acne | |
| ICD-9 Procedure | 86.24 | Chemosurgery of skin (includes chemical peel of skin) |
| ICD-9 Diagnosis | 702.0 | Actinic keratosis |
| 706.1 | Other acne (cystic, pustular, vulgaris, etc.) | |
| HCPCS | No code | |
| Type of Service | Therapy | |
| Place of Service | Physician’s office | |
Index
Chemical exfoliation
Chemical peels
Peels, chemical
Policy History
| Date | Action | Reason |
| 4/10/98 | Add to Therapy section | New policy |
| 7/10/98 | Replace policy | Policy revised; added CPT codes |
| 7/12/02 | Replace policy | Policy reviewed without literature review; new review date only |
| 10/09/03 | Replace policy | Policy reviewed by consensus; no changes in policy; no further review scheduled |
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