Medical Policy: 08.01.07 
Original Effective Date: January 1994 
Reviewed: March 2016 
Revised: March 2016 


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 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. 

Summary
Limited evidence supports the use of chemical peels for treating multiple actinic keratosis and as second line treatment of active acne. In 2014, the first placebo-controlled randomized trial evaluating chemical peels for active acne was published and this trial found significantly better outcomes after treatment with 40% glycolic acid peel compared with placebo treatment. There are no studies that demonstrate improved outcomes using chemical peels in the treatment of photoaged skin or acne-related scarring.  

 

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 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 when lesions are diffuse making treatments impractical, and when other field therapy treatments have either failed, are not tolerated, or are contraindicated.

 

Policy Guidelines and Position Statements
American Academy of Dermatology

In 2015, the American Academy of Dermatology published a guideline on the management of acne vulgaris which include the following statement: “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.”


Prior Approval:

 

Not applicable


Policy:

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 to treat each individual lesion: AND
  • Unless contraindicated,  the patient has failed a trial of topical chemotherapeutic agents (i.e. 5-flourouracil (5-FU) (Efudex) or topical medications (e.g. Aldara (Imiquimod))

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:

 

Surgical dermaplaning or carbon dioxide laser for removal of numerous (10 or more) 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 (e.g. 5-fluorouracil 5-FU) (Efudex)) or topical medications (e.g. 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 diagnosis 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)    

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.
  • American Academy of Dermatology: Actinic Keratosis: Diagnosis, Treatment and Outcome
  • Centers for Medicare &; Medicaid ServicesExternal Site National Coverage Determination (NCD) for Treatment of Actinic Keratosis (250.4).
  • National Comprehensive Cancer NetworkExternal Site (NCCN), Version 20214 Basal and Squamous Cell Skin Cancers.
  • American Academy of DermatologyExternal Site Acne: Diagnosis, Treatment and Outcome (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 SurgeonsExternal Site Chemical Peel.
  • American Society of Plastic SurgeonsExternal Site Dermabrasion.
  • Skin Cancer FoundationExternal Site Actinic Keratosis.
  • American Skin AssociationExternal Site Acne.
  • American Skin AssociationExternal Site Actinic Keratoses.
  • UpToDateExternal Site Treatment of Actinic Keratosis, Joseph Jorizzo, M.D., Topic last updated January 4, 2016.
  • UpToDateExternal Site Light-based, Adjunctive, and Other Therapies for Acne Vulgaris, Jeffrey S. Dover, M.D., FRCPC, Priya Batra, M.D.. Topic last updated August 6. 2015.
  • Medscape Reference DrugsExternal Site Diseases and Procedures, Dermabrasion. Updated December 13, 2013.
  • Medscape Reference Drugs, Diseases and Procedures, Acne Vulgaris, Updated May 13, 2013. MedscapeExternal Site 
  • National Comprehensive Cancer NetworkExternal Site (NCCN) Basal Cell Cancer, Version 1.2015.
  • National Comprehensive Cancer NetworkExternal Site (NCCN) Squamous Cell Skin Cancer, Version 1.2015.
  • 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
  • Kaminaka C, Uede M, Matsunaka H, et al. Clinical evaluation of glycolic acid chemical peeling in patients with acne vulgaris: a randomized, double-blind, placebo-controlled, split-face comparative study. Dermatol Surg. Mar 2014;40(3):314-322. PMID 24447110
  • Levesque A, Hamzavi I, Seite S, et al. Randomized trial comparing a chemical peel containing a lipophilic hydroxy acid derivative of salicylic acid with a salicylic acid peel in subjects with comedonal acne. J Cosmet Dermatol. Sep 2011;10(3):174-178. PMID 21896127 
  • Ilknur T, Demirtasoglu M, Bicak MU, et al. Glycolic acid peels versus amino fruit acid peels for acne. J Cosmet Laser Ther. Oct 2010;12(5):242-245. PMID 20825257
  • Kessler E, Flanagan K, Chia C, et al. Comparison of alpha- and beta-hydroxy acid chemical peels in the treatment of mild to moderately severe facial acne vulgaris. Dermatol Surg. Jan 2008;34(1):45-50; discussion 51. PMID 18053051
  • Kaminaka C, Yamamoto Y, Yonei N, et al. Phenol peels as a novel therapeutic approach for actinic keratosis and Bowen disease: prospective pilot trial with assessment of clinical, histologic, and immunohistochemical correlations. J Am Acad Dermatol. Apr 2009;60(4):615-625. PMID 19293009
  • de Berker D, McGregor JM, Hughes BR. Guidelines for the management of actinic keratoses. Br J Dermatol. Feb 2007;156(2):222-230. PMID 17223860
  • Zaenglein A, Pathy A, Schlosser B, et. al. Guidelines for Care for the Management of Acne Vulgaris. American Academy of Dermatology. J Am Acad Dermatol 2015.12.037

Policy History:

  • March 2016 - Annual Review, Policy Revised
  • April 2015 - Annual Review, Policy Renewed
  • May 2014 - Annual Review, Policy Revised
  • July 2013 - Annual Review, Policy Revised
  • November 2012 - Annual Review, Policy Renewed
  • November 2011 - Annual Review, Policy Renewed
  • November 2010 - 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.