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Medical Policy: 08.01.07
Original Effective Date: January 1994
Reviewed: November 2011
Revised: October 2002
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy 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 will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Chemical peels involve controlled removal of layers of the epidermis and superficial dermis through the use of a ‘wounding” agent such as phenol, trichloroacetic acid, Jessner’s solution, and alpha-hydroxy acids. Chemical peels can be used as a treatment for multiple actinic keratoses or other pre-cancerous lesions when treatment of numerous individual lesions is not practical, and for various stages of acne that is unresponsive to more conservative treatments. Chemical peeling also has a number of cosmetic uses including the treatment of photo-aged skin, uneven pigmentation, solar elastosis, and diminishing age-related wrinkles.
Dermabrasion is a planing procedure involving abrading the skin to promote reepithelialization with minimal scarring. Conventional methods include surgical scraping, carbon dioxide laser, cryotherapy, curettage, excision, and topical 5-fluorouracil for the removal of superficial basal cell carcinomas and pre-cancerous actinic keratoses. Dermabrasion also has a number of cosmetic applications such as diminishing age-related wrinkles and skin discolorations, minor scars and scaring from acne.
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Prior Approval:
Not applicable
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Policy:
Chemical peels may be considered medically necessary for the following indications:
- Treatment of numerous actinic keratoses or other pre-malignant lesions when treatment of individual lesions would be impractical AND, unless contraindicated, the patient has failed a trial of 5-flourouracil
- Treatment of active acne in patients who have failed topical medications and oral antibiotic therapy.
Dermabrasion treatments may be considered medically necessary for the following indications:
- Cryotherapy as a treatment of active acne
- Surgical dermaplaning or carbon dioxide laser for removal of numerous superficial basal cell carcinoma lesions, actinic keratoses or other pre-malignant lesions when the following criteria are met:
- Conventional methods of removal such as cryotherapy or curettage are impractical due to the high number of lesions AND
- Unless contraindicated, the patient has failed a trial of 5-fluorouracil
- Treatment of active acne in patients who have failed topical medications and oral antibiotic therapy.
Chemical peels and dermabrasion are considered not medically necessary for the following indications:
- Treatment of photo-aged skin, uneven pigmentation, and lentigines
- Treatment of acne-related scarring
- To diminish wrinkles
- Treatment of other condition primarily for cosmetic purposes or in the absence of functional impairment.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)
- 15781 Dermabrasion; segmental, face
- 15782 Dermabrasion; regional, other than face
- 15783 Dermabrasion; superficial, any site (eg, tattoo removal)
- 15788 Chemical peel, facial; epidermal
- 15789 Chemical peel, facial; dermal
- 15792 Chemical peel, nonfacial; epidermal
- 15793 Chemical peel, nonfacial; dermal
- 17340 Cryotherapy (CO2 slush, liquid N2) for acne
- 17360 Chemical exfoliation for acne (eg, acne paste, acid)
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Selected References:
- Morganroth, GS; Leffell, DT. Nonexcisional treatment of benign and premalignant cutaneous lesions. Clinics in Plastic Surgery 1993; 20:91-104.
- Brodland, DG; Roenigk, RK. Trichloroacetic acid chemexfoliation (chemical peel) for extensive premalignant actinic damage of the face and scalp. Mayo Clinic Proceedings 1988; 63:887-96.
- Van Scott, EJ; Yu, RJ. Alpha hydroxy acids: Procedures for use in clinical practice. Cutis 1989; 43:222-28.
- Kaminsky A. Less common methods to treat acne. Dermatology. 2003;206(1):68-73.
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Policy History:
Date Reason Action
November 2010 Annual review Policy renewed
November 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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