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Chemical Peels
11.08.08h

Policy

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 imiquimod (Aldara) 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 also 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 are 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 100mL). 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 October 9, 2023.

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 October 9, 2023.

Berman B. Treatment of actinic keratosis. [UpToDate Web site]. 09/29/2020. 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 October 9, 2023.

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.

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 October 9, 2023.

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

Lynch SA, Schwarz KA. Chapter 83: Chemical Peeling and Dermabrasion. Plastic Surgery Secrets Plus. 2nd ed. Mosby. 2010:549-53. doi:10.1016/b978-0-323-03470-8.00083-1. ​

McIntyre WJ, Downs MR, Bedwell SA. Treatment options for actinic keratoses. Am Fam Physician. 2007;76(5):667-71. 

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 October 9, 2023.
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 keratosis&source=search_result&selectedTitle=2~99&usage_type=default&display_rank=2 [via subscription only]. Accessed on October 9, 2023.

Strauss JS, Krowchuk DP, Leyden JJ, et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol. 2007;56(4):651-63.

Taub AF. Procedural treatments for acne vulgaris. Dermatol Surg. 2007;33(9):1005-26.

Van Scott EJ, Yu RJ. Alpha hydroxy acids: procedures for use in clinical practice. Cutis. 1989;43(3):222-8.

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):191-6.

Coding

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



Coding and Billing Requirements


Policy History

12/26/2022
12/26/2022
11/1/2023
11.08.08
Medical Policy Bulletin
Commercial
No