Medical Policy: 08.01.07
Original Effective Date: January 1994
Reviewed: April 2015
Revised: May 2014
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.
Chemical peels and dermabrasion are skin resurfacing procedures that remove the epidermis and superficial layers of skin to allow re-epitheliazation. Chemical peels and/or dermabrasion are types of treatment that are generally utilized for treating large areas where lesions are multiple and diffuse. Both procedures are established dermatological treatments for specific skin conditions and may be recommended for the treatment of precancerous skin lesions (i.e. actinic keratoses); however in many cases these methods of treatment do not improve function and are utilized for improving personal appearance. Treatments intended to improve personal appearance or that do not improve functional deficits are considered cosmetic in nature.
Chemical peels involve controlled removal of varying layers of the skin with the use of a chemical 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.
Chemical peels are often categorized according to the depth of the peel:
Light Chemical Peel: This kind of peel removes just the outer layer of the skin (epidermis) in a light exfoliation.
Medium Chemical Peel: The chemicals used for this type of peel remove skin cells from both the outer layer of skin (epidermis) and upper part of your middle layer of skin (dermis).
Deep Chemical Peel: The chemical used for this type of peel penetrates down to the lower dermal layer. A deep chemical peel usually involves a pretreatment for up to eight weeks to prepare the skin for the peel and to speed the healing process.
Dermabrasion is a surgical procedure that resurfaces the texture of the skin by removing its top layer using a mechanical instrument such as high speed rotary abrasive wheel to remove the layers of skin.
Other modalities of treatment used in place of conventional dermabrasion include laser brasion which involves the use of the argon laser, ultrapulse carbon dioxide (CO2) laser, or flashlamp-pumped pulsed dye laser and chemobrasion which involves the use of phenol, trichloroacetic acid and glycolic acid).
Dermabrasion was initially developed to combat acne scars; this is the most common indication of its use. It has also been used to manage superficial basal cell carcinoma and 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.
Dermabrasion is contraindicated in patients with active acne, as active stages of acne pose a greater risk of infection and may exacerbate skin inflammation.
Microdermabrasion is a non-invasive, non-surgical cosmetic procedure that can be performed either by a physician or in some cases by the individual in a home setting. The non-invasive treatment exfoliates or removes the top layer of skin (i.e. stratum corneum) and is frequently performed to diminish the signs of aging. Dermabrasive procedures that resurface the superficial layer of skin, including but not limited to those used to reduce signs of aging, are considered cosmetic.
Chemical peels may be considered medically necessary for the following indications:
- Treatment of numerous (10 or more) 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 topical chemotherapeutic agents (i.e. 5-flourouracil) or topical medications (i.e. Aldara (Imiquimod))
- 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:
- 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 electrodessication and curettage are impractical due to the high number and distribution of lesions AND
- Unless contraindicated, the patient has failed a trial of topical chemotherapeutic agents (i.e. 5-fluorouracil) or topical medications (i.e. Aldara (Imiquimod))
Dermabrasion for the treatment of active acne is considered not medically necessary, as this treatment is contraindicated in patients with active acne, as active stages of acne pose a greater risk of infection and may exacerbate skin inflammation.
Chemical peels and dermabrasion would be considered cosmetic in nature and therefore not a contract benefit for the following indications, but not limited to:
- 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.
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
- 17360 Chemical exfoliation for acne (eg, acne paste, acid)
- 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.
- American Academy of Dermatology: Actinic Keratosis: Diagnosis, Treatment and Outcome
- Centers for Medicare & Medicaid Services, National Coverage Determination (NCD) for Treatment of Actinic Keratosis (250.4). www.cms.gov
- National Comprehensive Cancer Network (NCCN), Version 20214 Basal and Squamous Cell Skin Cancers. www.nccn.org
- American Academy of Dermatology: Acne: Diagnosis, Treatment and Outcome. www.aad.org/dermotology a to z
- American Academy of Dermatology: Guidelines of Care for Acne Vulgaris Management. J Am Acad Dermatol 2007;56:561-63
- American Society of Plastic Surgeons, Chemical Peel. www.plasticsurgery.org
- American Society of Plastic Surgeons, Dermabrasion. www.plasticsurgery.org
- Skin Cancer Foundation, Actinic Keratosis. www.skincancer.org
- American Skin Association, Acne. www.americanskin.org
- American Skin Association, Actinic Keratoses. www.americanskin.org
- UpToDate. Treatment of Actinic Keratosis, Joseph Jorizzo, M.D., Topic last updated June 21, 2013. www.uptodate.com
- UpToDate. Light-based, Adjunctive, and Other Therapies for Acne Vulgaris, Jeffrey S. Dover, M.D., FRCPC, Priya Batra, M.D.. Topic last updated September 9, 2013. www.uptodate.com
- Medscape Reference Drugs, Diseases and Procedures, Dermabrasion. Updated December 13, 2013. http://emedicine.medscaope.com
- Medscape Reference Drugs, Diseases and Procedures, Acne Vulgaris, Updated May 13, 2013. http://emedicine.medscape.com
- National Comprehensive Cancer Network (NCCN) Basal Cell Cancer, Version 1.2015. Also available at www.nccn.org
- National Comprehensive Cancer Network (NCCN) Squamous Cell Skin Cancer, Version 1.2015. Also available at www.nccn.org
- British Association of Dermatologists, Guidelines for the Management of Actinic Keratoses 2007. British Journal of Dermatology 2007 156, pp 222-230
- American Academy of Dermatology, Guidelines of Care for Acne Vulgaris Management, 2007. Journal of American Academy of Dermatology 2007;56:651-63
Date Reason Action
November 2010 Annual review Policy renewed
November 2011 Annual review Policy renewed
November 2012 Annual review Policy renewed
July 2013 Annual review Policy revised
May 2014 Annual review Policy revised
April 2015 Annual review Policy renewed
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 © 2012 American Medical Association. All Rights Reserved.