Medical Policies - Surgery


Chemical Peels

Number:SUR716.018

Effective Date:07-01-2018

Coverage:

*CAREFULLY CHECK STATE REGULATIONS AND/OR THE MEMBER CONTRACT*

This medical policy does NOT address Gender Reassignment Services (Transgender Services). This medical policy IS NOT TO BE USED for Gender Reassignment Services. Refer to SUR717.001, Gender Assignment Surgery and Gender Reassignment Surgery and Related Services

Dermal chemical peels to treat patients with numerous (greater than 10) actinic keratoses or other premalignant skin lesions may be considered medically necessary if treatment of the individual lesions becomes impractical.

Dermal chemical peels to treat end-state acne scarring are considered cosmetic.

Epidermal chemical peels to treat photoaged skin, wrinkles, or acne scarring are considered cosmetic.

NOTE: For treatment of acne see Acne Management, THE801.028

Description:

A chemical peel refers to 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. However, chemical peeling has also been used as a treatment 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 2-3 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. (1)

Types of Peels

Chemical peels are often categorized by 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 in 2005 by Cummings et al. (2) and others, is as follows.

Superficial Peels

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

Medium-depth peels (dermal peels) extend into the epidermis to the papillary dermis. They 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 high rates of complications (e.g., pigmentary changes, 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 (e.g., superficial chemical peels) and repeat medium-depth chemical peels should not be performed for at least 1 year.

Deep Peels

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 events 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 (i.e., 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.

Applications

Chemical peels are a potential treatment option for actinic keratoses. 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%. (3) These lesions are generally considered to be a precursor of squamous cell carcinoma. (4) The risk of progression to invasive squamous cell carcinoma is unclear, but estimates vary from 0.1% to 20%. (3) For patients with multiple actinic keratoses, the risk of developing invasive squamous cell carcinoma is estimated as being between 0.15% and 80%. Treatment options include watchful waiting, medication treatment, cryosurgery and, surgical resection.

Regulatory Status

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.

Rationale:

A major issue for the policy is the determination of whether the treatment is primarily cosmetic in nature. Regarding actinic keratoses, these are premalignant lesions, and the medical necessity for their destruction/removal is considered appropriate, although watchful waiting may also be an option. Review articles have suggested that chemical peels might be appropriate when there are numerous lesions (i.e., ≥10), making treatment of the individual lesions impractical, and when the treatment constitutes a full-thickness necrosis of the epidermis, which is considered curative. (7, 8)

This policy reviews the clinical evidence to determine whether the use of a technology improves the net health outcome. Broadly defined, health outcomes are length of life, quality of life, and ability to function - including benefits and harms. Every clinical condition has specific outcomes that are important to patients and to managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of a technology, 2 domains are examined: the relevance and the quality and credibility. To be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. RCTs are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice. The key literature is described below.

Actinic Keratoses

Evaluating the effect of using chemical peels on patients with actinic keratosis, compared with alternatives such as watchful waiting, topical or oral medications, destructive treatments, or photodynamic therapy, would ideally include well-controlled comparative studies, such as 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 the harms of associated treatment-related morbidities.

RCTs evaluating chemical peels for treatment of actinic keratoses were not identified. One nonrandomized split-face study was identified. This 1995 trial by Lawrence et al. evaluated 15 male patients with multiple facial actinic keratoses in similar numbers on both sides of the face. (5) Patients were treated on the left side with a single application of Jessner solution plus trichloroacetic acid 35% and on the right side with fluorouracil cream 5% twice daily for 3 weeks. The efficacy of both treatments was similar. The difference in the number of actinic keratoses on the left versus right side of the face was not statistically significant at 6 or 12 months (p>0.01). Both treatments were associated with non-serious adverse events. On the chemical peel side of the face, patients developed erythema and mild desquamation lasting an average of 10 days in all but 1 patient, for whom the adverse event lasted 3 months. On the fluorouracil cream side of the face, there was erythema, scaling, erosion, and crusting; these adverse events persisted an additional 2 to 3 weeks beyond 3-week treatment period.

Kaminaka et al. (2009) reported on a prospective case series from Japan that included 46 patients, 32 with actinic keratoses and 14 with Bowen disease. (6) There was no minimum number of actinic keratoses required for inclusion; i.e., the study did not specifically address the treatment of multiple actinic keratoses. Patients received peels with 100% pure phenol applied locally to the lesions once a month for a maximum of 8 months (or less than 8 months if a complete response was achieved sooner). Biopsies were performed on all lesions before and at the end of therapy. Twenty-nine (91%) of the 32 patients with actinic keratoses achieved a complete response (defined as an undetectable lesion at least 1 month after the last phenol application). The average number of treatments for patients with actinic keratoses was 2.9. Ten (83%) of the 12 patients with Bowen disease had a complete response, and the average number of treatments in this group was 5.5. All patients were followed for at least 1 year after treatment (median follow-up, 2.8 years). By the 1-year follow-up, 2 (4.3%) of 46 patients, one with actinic keratoses and one with Bowen disease, had experienced recurrences. No systemic adverse events were reported. The study lacked a control group and enrolled few subjects, especially in the subset of patients with Bowen disease.

Summary of Evidence

For individuals who have actinic keratoses who receive dermal chemical peels, the evidence includes a nonrandomized split-face study and case series. Relevant outcomes are symptoms, morbid events, quality of life, and treatment-related morbidity. The split-face study found similar outcomes after a single chemical peel or 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 keratoses treated with phenol peels. Additional controlled studies, preferably randomized, are needed. The evidence is insufficient to determine the effects of the technology on health outcomes.

Clinical Input from Physician Specialty Societies and Academic Medical Centers

In 2010, the Blue Cross Blue Shield Association (BCBSA) requested and received clinical input from 3 physician specialty societies and 4 academic medical centers while this policy was under review. Input was consistently in agreement with the medically necessary indications for dermal and epidermal chemical peels.

Ongoing and Unpublished Clinical Trials

A search of ClinicalTrials.gov in November 2017 did not identify any ongoing or unpublished trials that would likely influence this policy.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

15788, 15789, 15792, 15793

HCPCS Codes

None

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.

A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

1. Habif TP. Clinical Dermatology 5th Edition. Philadelphia, PA: Mosby/Elsevier; 2010.

2. Cummings CW, Haughey BH, Thomas JR, et al. Otolaryngology: Head and Neck Surgery, 4th edition. St Louis, MO: Mosby; 2005.

3. Costa C, Scalvenzi M, Ayala F, et al. How to treat actinic keratosis? An update. J Dermatol Case Rep. Jun 30 2015; 9(2):29-35. PMID 26236409

4. Padilla RS, Sebastian S, Jiang Z, et al. Gene expression patterns of normal human skin, actinic keratosis, and squamous cell carcinoma: a spectrum of disease progression. Arch Dermatol. Mar 2010; 146(3):288-293. PMID 20231500

5. Lawrence N, Cox SE, Cockerell CJ, et al. A comparison of the efficacy and safety of Jessner's solution and 35% trichloroacetic acid vs 5% fluorouracil in the treatment of widespread facial actinic keratoses. Arch Dermatol. Feb 1995; 131(2):176-181. PMID 7857114

6. 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

7. Brodland DG, Roenigk RK. Trichloroacetic acid chemexfoliation (chemical peel) for extensive premalignant actinic damage of the face and scalp. Mayo Clin Proc. Sep 1988; 63(9):887-896. PMID 3412028

8. Morganroth GS, Leffell DJ. Nonexcisional treatment of benign and premalignant cutaneous lesions. Clin Plast Surg. Jan 1993; 20(1):91-104. PMID 8420713

9. Chemical Peels. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2017 December) Therapy 8.01.16.

Policy History:

Date Reason
7/1/2018 Document updated with literature review. Coverage unchanged. References 3-5 were added; one reference was removed.
4/15/2017 Reviewed. No changes.
5/1/2016 Document updated with literature review. Coverage unchanged.
10/1/2015 Reviewed. No changes.
3/1/2014 Document updated with literature review. Coverage unchanged. CPT/HCPCS codes updated.
9/1/2009 Literature search, no change in coverage.
9/15/2007 Revised/Updated Entire Document
10/15/2008 Revised/Updated Entire Document
7/24/2004 Codes Revised/Added/Deleted
11/1/2000 Revised/updated entire document
9/1/1999 New medical document

Archived Document(s):

Title:Effective Date:End Date:
Chemical Peels04-15-201706-30-2018
Chemical Peels05-01-201604-14-2017
Chemical Peels10-01-201504-30-2016
Chemical Peels03-01-201409-30-2015
Chemical Peels09-01-200902-28-2014
Chemical Peels09-15-200708-31-2009
Chemical Peels10-15-200509-14-2007
Chemical Peels07-27-200410-14-2005
Chemical Peels11-01-200007-26-2004
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