Medical Policy: 08.01.07
Original Effective Date: January 1994
Reviewed: March 2017
Revised: March 2017
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, the precise depth of the peel depends on the concentration of the agent used, duration of the application, and the number of applications:
Superficial/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.
Actinic keratoses (pre-malignant lesions) are common skin lesions associated with extended exposure to the sun, with estimated prevalence in the United States of 11% to 26%. These lesions are generally considered to be a precursor of squamous cell carcinoma (SCC). The risk of progression to invasive SCC is unclear, but estimates vary from 0.1% to 20%. For patients with multiple actinic keratosis, the risk of developing invasive SCC is estimated as being between 0.15% and 80%. Treatment options include watchful waiting, medication treatment, cryosurgery, chemical peel, and surgical resection.
Evaluating the effect of using chemical peels on patients with actinic keratoses, compared to alternatives such as watchful waiting, topical or oral medications, destructive treatments, or photodynamic therapy, would ideally include well controlled comparative studies, such as randomized controlled trials (RCTs) with follow up to compare outcomes such as occurrence of malignancy and treatment related morbidity. Alternatively, comparison of robust observational studies may help to demonstrate the comparative effectiveness of treatment options by showing the benefit in destroying actinic keratosis, the durability of this effect, and harms of associated treatment related morbidities.
RCTs evaluating chemical peels for treatment of actinic keratosis were not identified. One nonrandomized split-face study was identified. The split-face trial found similar outcomes after single chemical peel and after 3 weeks of treatment with fluorouracil cream 5% in 15 patients. A case series found high response rates and low recurrence rates at 1 year in patients with actinic keratosis treated with phenol peels. Additional controlled studies, preferably randomized are needed. However, clinical input obtained in 2010 supported the use of chemical peels for the treatment of actinic keratoses when there are numerous lesions, making treatment of the individual lesions impractical and they have failed to respond to treatment with topical 5-FU or imiquimod, unless contraindicated.
Acne vulgaris is the most common skin condition among adolescents, affecting an estimated 80% of 13 to 18 year olds. Acne, particularly moderate-to-severe manifestations, can cause psychological distress including low self-esteem, depression and anxiety. There are a variety of oral and topical treatments for acne. An additional treatment option includes chemical peels.
Evaluating the effect of chemical peels on active acne compared to alternatives (e.g. topical or oral medication) would ideally include well controlled comparative studies, such as RTC’s with follow up for outcomes such as resolution of severe acne and occurrence of disease related psychologic symptoms (e.g. depression, anxiety). For individuals who have moderate-to-severe active acne who receive chemical peels, the evidence includes randomized controlled trials (RCTs). One small randomized trial was placebo-controlled, it found greater efficacy with active treatment than placebo. Several RCTs comparing chemical peel agents in patients with acne have generally reported comparable improvement with types of chemical peel agents studied. However, no studies were identified comparing chemical peel agents with conventional acne treatment. Additional comparative randomized controlled trials are needed. However, clinical input from physician specialty societies and academic medical centers obtained in 2010 supported the use of chemical peels as a second line treatment of active moderate to severe acne.
Dermabrasion is a dermatologic procedure that exerts its therapeutic effect by removing the epidermis and superficial dermis, allowing re-epithelialization from the underlying skin to occur. With dermabrasion, a specialized hand held instrument is used to “sand” the skin, removing the epidermal surface in order to improve contour. Therefore, this technique is best used for superficial lesions of the face.
Standard dermabrasion uses a wire brush or diamond fraise (a stainless steel wheel which diamond chips have been bonded) abraders to plan the skin whereas laser dermabrasion involves the use of the argon laser, ultrapulse carbon dioxide (CO2) laser, or flashlamp-pumped pulsed dye laser to resurface the entire face, and has been used as an alternative to standard dermabrasion in treating patients with active acne with scarring.
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 has proven effective in treating multiple recalcitrant actinic keratoses (AK) lesions in cases where numerous AK lesions (e.g. more than 10) have been documented and where lesions are diffuse with severe actinic damage. In general, AK lesions are precancerous skin lesions that occur on the epidermis (outer layer of the skin) and result from long-term exposure to the sun. 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.
Summary: Dermabrasion have been proven safe and effective for removal of superficial basal cell carcinomas and treatment of actinic keratoses when lesions are diffuse making treatments impractical, and when other conventional methods of treatments have either failed, are not tolerated, or are contraindicated.
In 2016, the American Academy of Dermatology published a guideline on the management of acne vulgaris makes include the following statement regarding chemical peels: “Miscellaneous Therapies and Physical Modalities: Studies exist suggesting that chemical peels may improve acne. However, large, multicenter, double blinded control trials comparing peels to placebo and comparing different peels are lacking. Glycolic acid and salicylic acid chemical peels may be helpful for non-inflammatory (comedonal) lesions. However, multiple treatments are needed and the results are not long lasting. In the opinion of the work group, chemical peels may result in mild improvement in comedonal acne.”
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 active acne in patients who have failed a trial of topical and/or oral antibiotic acne therapy. (In this setting superficial chemical peels with 40% to 70% alpha hydroxyl acids are used as a comedolytic therapy). (Alpha hydroxyl acids can also be used in lower concentrations (8%) without the supervision of a physician)
Dermabrasion treatments may be considered medically necessary for the following indications:
Dermabrasion using conventional method of controlled surgical scraping (dermaplaning) or carbon dioxide (CO2) laser for removal of superficial basal cell carcinoma lesions, actinic keratoses or other pre-malignant lesions when the following criteria are met:
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, including but not limited to:
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.