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DESCRIPTIONA chemical peel is a controlled removal of varying layers of the skin with use of a chemical agent. The most common use for chemical peeling is as a treatment of photoaged skin. Chemical peeling has also been used for other conditions, including actinic keratoses, active acne, and acne scarring.
Chemical peels involve a controlled partial-thickness removal of the epidermis and the outer dermis. When skin is regenerated, a 2- to 3-mm band of dense, compact collagen is formed between the epidermis and the damaged layers of the dermis, resulting in ablation of fine wrinkles and a reduction in pigmentation. These changes can be long-term, lasting 15 to 20 years and may be permanent in some patients. Potential local complications include scarring, infection, hypopigmentation, hyperpigmentation, activation of herpes simplex, and toxic shock syndrome.
Chemical peels are often categorized according to the depth of the peel: categories include superficial, medium-depth, and deep chemical peels. The precise depth of the peel depends on the concentration of the agent used, duration of the application, and the number of applications. Possible indications for each type of peel and common chemicals used, as described by Cummings and colleagues, is as follows:
Superficial peels (epidermal peels) affect the epidermis and the interface of the dermis-epidermis. This depth is considered appropriate for treating mild photoaging, melasma, comedonal acne, and postinflammatory erythema. Common chemical agents used for superficial peels include low concentrations of glycolic acid, 10% to 20% trichloroacetic acid (TCA), Jessner solution (a mixture of resorcinol, salicylic acid, lactic acid, and ethanol), tretinoin, and salicylic acid. As part of the treatment process, superficial peels generally cause mild erythema and desquamation, and healing time ranges from 1 to 4 days, depending on the strength of the chemical agent. With superficial peels, patients often undergo multiple sessions, generally 6 to 8 peels performed weekly or biweekly.
Medium-depth peels (dermal peels) extend into the epidermis to the papillary dermis. These are used for moderate photoaging, actinic keratoses, pigmentary dyschromias, and mild acne scarring. In the past, 50% TCA was a common chemical agent for medium-depth peels, but its use has decreased due to a high rate of complications such as pigmentary changes and scarring. Currently, the most frequently used agent is a combination of 35% TCA with Jessner solution or 70% glycolic acid. Phenol 88% alone is also used for medium-depth peels. The healing process involves mild to moderate edema, followed by the appearance of a new, erythematous epithelium. Patients are advised to wait at least 3 months before resuming skin care services (eg, superficial chemical peels) and repeat medium-depth chemical peels should not be performed for at least one year.
Deep chemical peels (another type of dermal peel) penetrate the midreticular dermis and have been used for patients with severe photodamage, premalignant skin neoplasms, acne scars, and dyschromias. The most common chemical agent used is Baker solution (which consists of 3 mL of 88% phenol, 8 drops of hexachlorophene (Septisol), 3 drops of croton oil, 2 mL of distilled water). The same depth can be achieved using 50% or greater TCA peel; however, the latter has a higher risk of scarring and pigmentation problems. Phenol is cardiotoxic, and patients must be screened for cardiac arrhythmias or medications that could potentially precipitate an arrhythmia. Phenol can also have renal and hepatic toxicities.
The likelihood and potential severity of adverse effects increases as the strength of the chemicals and depth of peels increases. With deep chemical peels, there is the potential for long-term pigmentary disturbances (ie, areas of hypopigmentation), and selection of patients willing to always wear makeup is advised. Moreover, chemical peels reduce melanin protection, so patients must use protective sunscreen for 9 to 12 months after a medium- to deep-facial peel.
Chemical peels are a potential treatment option for actinic keratoses and moderate-to-severe acne. Actinic keratoses are common skin lesions associated with extended exposure to the sun, with an 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 keratoses, the risk of developing invasive SCC is estimated as being between 0.15% and 80%. Treatment options include watchful waiting, medication treatment, cryosurgery, surgical resection.
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 psychologic distress including low self-esteem, depression, and anxiety. There are a variety of oral and topical treatments for acne.
U.S. Food and Drug Administration (FDA) clearance or approval of chemical agents used in peeling may not be relevant because these agents are prepared in-office, may have predated FDA approval, and/or may be considered cosmetic ingredients.
Related medical policy -
POLICYAny of the following treatments for acne that does not involve the face will be considered not medically necessary.
Epidermal chemical peels used to treat photo-aged skin, wrinkles, or acne scarring is considered cosmetic.
Dermal chemical peels as a treatment of end-stage acne scarring is considered cosmetic.
Dermal chemical peels used to treat patients with numerous (greater than 10) actinic keratoses or other premalignant skin lesions, such that treatment of the individual lesions becomes impractical, may be considered medically necessary.
Epidermal chemical peels used to treat patients with active acne that have failed a trial of topical and/or oral antibiotic acne therapy are considered medically necessary. In this setting superficial chemical peels with 40%-70% alpha hydroxy acids are used as a comedolytic therapy. (Alpha hydroxy acids can also be used in lower concentrations [8%] without the supervision of a physician.)
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Requests for all chemical peels should be carefully evaluated to determine whether their rationale is primarily cosmetic. Epidermal peels would only be considered medically necessary in patients with active acne who have failed other therapy. Dermal peels would be considered medically necessary only in patients with multiple actinic keratoses.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
POLICY HISTORY9/1994: Dermabrasion policy approved by Medical Policy Advisory Committee (MPAC)
5/1998: Policy revision approved by MPAC; policy renamed Chemical Peels
3/19/2002: "Review on an individual basis" requirement deleted
4/18/2002: Type of Service and Place of Service deleted
9/4/2002: Policy section revised.
11/5/2003: Code Reference section updated, CPT 15792, 15793 moved from covered to non-covered
6/15/2004: Code Reference section updated, CPT 15792, 15793 moved from non-covered to covered, ICD-9 diagnosis code 232.0, 232.1, 232.2, 232.3, 232.4, 232.5, 232.6, 232.7, 232.8, 232.9, 238.2 added to covered codes, Non-covered table deleted, Sources updated
1/7/2009: Policy reviewed, no changes
06/22/2010: Policy statement revised to state that dermal chemical peels as a treatment of end-stage acne scarring is considered cosmetic. Deleted the following policy statement: Treatment of hyperpigmentation is medically necessary only when it is secondary to previous medical treatment originally performed for medically necessary, not cosmetic reasons. Due to the policy statement changes, ICD-9 codes 374.52, 695.3, 701.4, 709.00, 709.09, and 709.2, which describe hyperpigmentation and end-stage acne scarring, were deleted from the Covered Codes table. Policy guidelines updated regarding evaluation for cosmetic versus medically necessary treatment. Deleted outdated references from the Sources section.
07/16/2010: Policy reviewed; no changes.
08/03/2011: Policy reviewed; no changes.
09/25/2012: Policy reviewed; no changes.
11/06/2013: Policy reviewed; no changes.
09/24/2014: Policy reviewed; description revised. Medically necessary policy statement regarding epidermal chemical peels used to treat active acne revised to change the concentration of alpha hydroxy acids from "50%-70%" to "40%-70%."
08/25/2015: Code Reference section updated for ICD-10.
10/22/2015: Policy description updated. Policy statements unchanged. Policy guidelines section updated to add medically necessary definition.
05/25/2016: Policy number A.8.01.16 added.
01/19/2017: Policy description updated regarding actinic keratoses and acne vulgaris. Policy statements unchanged.
SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.16
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.