Chemical Peels and Dermabrasion*

Medical Policy: 08.01.07
Original Effective Date: January 1994
Reviewed: January 2008
Revised: October 2002

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

Description:

Dermabrasion: It is a planing procedure of abrading disfigured skin to promote reepithelialization with minimal scaring. The conventional methods are controlled surgical scraping, carbon dioxide laser, cryotherapy, curettage, excision and 5-FU for the removal of superficial basal cell carcinomas and pre-cancerous actinic keratoses. It is also used for various cosmetic applications such as removing age related wrinkles, variations in skin coloration, minor scars and scaring from end stage acne.
Chemical peel: It is a 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 (resorcin, salicylic and lactic acid), 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 is also used as a cosmetic treatment for various applications such as of photoaged skin, uneven pigmentation, solar elastosis and wrinkles.

Policy:

Chemical peel and dermabrasion services may be considered medically necessary as explained below:

Dermabrasion: Cryotherapy may be considered medically necessary for the treatment of active acne
Dermabrasion: May be considered medically necessary using the conventional controlled surgical dermaplaning or carbon dioxide laser for removal of numerous superficial basal cell carcinomas or pre-cancerous actinic keratoses when the following applicable criteria are met:
- Conventional methods of removal such as cryotherapy or curettage are impractical due to the high number of lesions (15 or more lesions)
- A trial of 5-fluorouracil (5-Fu) has been tried and failed, unless it is considered contraindicated
- Dermabrasion may be considered medically necessary when used to treat patients with active acne who have failed a trial of topical medications and oral antibiotic therapy
Chemical Peel:
- Medium and deep chemical peels for numerous actinic keratoses or other pre-malignant skin lesions may be considered medically necessary when treatment of the individual lesions would be impractical due to the number (15 or more lesions) AND
- A trial of 5-fluorouracil (5-Fu) has been tried and failed, unless it is considered contraindicated
- Chemical peels may be considered medically necessary when used to treat patients with active acne who have failed a trial of topical medications and oral antibiotic therapy

Chemical peels and dermabrasion are not covered benefits because they are not considered medically necessary under the following circumstances:

When used to correct photoaged skin, uneven pigmentation, wrinkles, lentigines or end stage acne scarring because these are considered cosmetic in nature
When used to treat other conditions primarily for cosmetic purposes or in the absence of a functional impairment

Prior approval of chemical peels and dermabrasion is recommended for all diagnoses other than active acne. Submit a prior approval now.

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Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
CPT code 15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)
CPT code 15781 Dermabrasion; segmental, face
CPT code 15782 Dermabrasion; regional, other than face
CPT code 15783 Dermabrasion; superficial, any site (eg, tattoo removal)
CPT code 15788 Chemical peel, facial; epidermal
CPT code 15789 Chemical peel, facial; dermal
CPT code 15792 Chemical peel, nonfacial; epidermal
CPT code 15793 Chemical peel, nonfacial; dermal
CPT code 17340 Cryotherapy (CO2 slush, liquid N2) for acne
CPT code 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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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:

Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave.
Des Moines, IA 50309

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.