BlueCross and BlueShield of Montana Medical Policy/Codes
Chemical Peels
Chapter: Medicine: Treatments
Current Effective Date: November 26, 2013
Original Effective Date: August 05, 1999
Publish Date: August 26, 2013
Revised Dates: February 11, 2004; March 1, 2005; March 1, 2010; Otober 2, 2012; August 20, 2013
Description

A chemical peel refers to a controlled removal of varying layers of the epidermis and superficial dermis with the use of a wounding agent, such as phenol or TCA.  Chemical peels can be subdivided into the types of wounding agents used and the depth of the peel, either epidermal or dermal.

Since the days of ancient Egypt, chemoexfoliation methods also known as chemical peeling has been used to rejuvenate skin.  The original chemoexfoliant was lactic acid, an active ingredient of sour milk that was used topically by the nobles as a part of an ancient skin rejuvenation regimen.

In the Middle Ages, old wine with tartaric acid as its active ingredient was used for the same purpose.  Today, these historical chemoexfoliants are known to contain alpha-hydroxyl-acids, which are the active ingredients responsible for skin exfoliation.

The chemical peel produces a controlled partial thickness injury to the skin.  Following the insult to the skin, a wound healing process ensues that can regenerate epidermis from surrounding epithelium and adnexal structures, decrease solar elastosis (seen histologically in the sun-exposed skin of the elderly or in those who have chronic actinic damage), and replace and reorient the new dermal connective tissue.  The result is an improved clinical appearance of the skin, with fewer rhytides (wrinkles) and decreased pigmentary dyschromia (abnormal color).

Modern day chemical peeling originally was promoted by dermatologists, such as P.G. Unna, who first described the proprieties of salicylic acid, resorcinol, phenol, and TCA.  Slowly, the early practitioners of chemical peels began to develop other peeling agents for varying depths of penetration.      

Superficial Peeling Agents (Epidermal Peels)

  • Trichloroacetic acid (TCA) (10-35%) has been used for many years and is safe to use at lower concentrations.  At higher concentrations of 50% and above, TCA has a tendency to scar and is less manageable than other agents used for superficial peels found in several proprietary peels at varying concentrations.
  • Jessner’s peel is a combination of salicylic acid 14%, lactic acid 14%, and resorcinol 14% in alcohol.  This agent is easy to use with no timing necessary. 
    1. The agent is applied to the face.
    2. When a light frost forms on the skin.
    3. Neutralize with water.
  • Salicylic acid has been used for several decades and is found in medications, such as Whitfield’s ointment at 4%, and Ver-Sal at 17% concentrations.  Salicylic acid is lipid soluble; therefore, it is a good peeling agent for comedonal acne (necrotizing).  The salicylic acid is able to penetrate the comedones better than other acids.  The anti-inflammatory and anesthetic effects of the salicylate result in a decrease in the amount of erythema and discomfort that generally is associated with chemical peels.  The most common concentration today is 20% to 30%.
  • Carbon dioxide, when used for a chemical peel, uses a solid block of carbon dioxide ice dipped in an acetone-alcohol mixture and then applied to the skin for 5 to 15 seconds, depending upon the desired depth.  Carbon dioxide is easier to use, and the depth of the peel can be controlled more easily than with liquid nitrogen.  Carbon dioxide has a temperature of 78ْ degrees Celsius while liquid nitrogen has a temperature of 196ْ degrees Celsius.
  • Alpha-hydroxy-acid peels include lactic acid, glycolic acid, tartaric acid, and malic acid that are synthesized chemically for use in peels.  Various concentrations are available, with 10% to70% concentrations used for facial peels, most commonly 50% or 70%.

Medium-Depth Peels (Epidermal or Dermal)

  • Three combination peels currently being used are carbon dioxide and TCA 35%, Jessner’s and TCA 35%, and glycolic acid and TCA 35%.  These peels are as effective as the other medium-depth peels with less chance of scarring and pigment dyschromia.  An endless number of combinations are possible.  TCA 50% is seldom used because of a higher risk of scarring and the availability of the combination peels.
  • Full strength phenol (88%) is a very caustic agent that causes immediate keratin agglutination, preventing further penetration of the agent deeper into the dermis.  The increased risk of scarring and pigment dyschromia makes this agent less attractive to the practitioner.  If diluted and mixed with other complementary chemicals, this agent can be used effectively as a deep peeling agent.
  • Pyruvic acid is rarely used today because of its fast action which causes difficulty in controlling the depth.  A product currently is being developed that uses ethyl pyruvate and has a higher pH and greater buffering ability than other related products.

Deep Peels (Dermal Peels)

The Baker Gordon peel (phenol 88%, 2ML distilled water, 8 drops Septisol, and 3 drops croton oil) produces the most dramatic results and is the most effective peeling agent currently used.  The phenol produces a new zone of collagen that is thicker than produced by laser.  The solution is very effective in smoothing wrinkles related to aging and sun damage.

  • This advantage is countered by several disadvantages.  A long healing time is required, with erythema occasionally lasting as long as six months.  In addition, the potential for pigmentary changes, scarring, and infection are high with this peel.  Despite the problems that may be encountered, a properly administered phenol peel has had better results than other peeling agents, and for perioral wrinkles, the phenol peel even surpassed laser resurfacing.  Although dramatic results can be achieved with a phenol peel, the risks and benefits should be weighed carefully before proceeding.  Only experienced clinicians should attempt a phenol agent based peel.
  • The Baker Gordon solution penetrates into the middle reticular dermis and requires special monitoring devices, such as an electrocardiogram (ECG) monitor and oximeter, because there is a potential that phenol may cause arrhythmias.  This formula is seldom used because of resurfacing laser technology; however, a deep peel works well on deep perioral rhytides.  Deep peels can be occluded or nonoccluded.  The occluded method uses zinc oxide tape or other artificial barrier product to prevent evaporation of the phenol from the skin, thus enabling the solution to penetrate deeper.  (Two variants of the Baker Gordon peel are Litton's formula, which replaces Septisol with glycerin, and the Beeson McCollough formula, which uses aggressive defatting and heavier application of Baker Gordon solution.)
Policy

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 is any exclusion 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.

Coverage

Blue Cross and Blue Shield of Montana (BCBSMT) considers use of superficial and medium depth peeling agents (epidermal chemical peels) to treat photoaged skin wrinkles or acne scarring cosmetic. Agents include, but are not limited to:

  • Trichloroacetic acid (TCA) 10 – 35% solution;
  • Jessner’s Peel;
  • Salicylic acid, 20 – 30% solution;
  • Carbon Dioxide;
  • Alpha-hydroxy acid, 10 – 70% concentrations.

BCBSMT may consider medium depth dermal chemical peels to treat patients with numerous (greater than ten) actinic keratosis or other premalignant skin lesions medically necessary if treatment of the individual lesions becomes impractical.  Treatments in this category include but are not limited to:

  • Carbon dioxide and TCA 35%;
  • Jessner’s and TCA 35%;
  • Glycolic acid and TCA 35%;
  • Phenol 88%;
  • Pyuvic Acid.

Special Comment regarding Cosmetic Services:  Determination of benefit coverage for procedures considered to be cosmetic is based on how a member's benefit contract defines cosmetic services and their eligibility for benefit coverage.

Rationale

The main issue regarding chemical peels is the determination of whether the treatment is primarily cosmetic in nature.  Actinic keratoses are premalignant lesions, and the medical necessity for their destruction or removal is considered appropriate, although watchful waiting may also be an option.  However, a chemical peel for the treatment of actinic keratoses would only be appropriate when there are numerous lesions, making treatment of the individual lesions impractical.  For example, Morganroth and Leffell suggest that patients with fewer than 10 actinic keratoses should be treated with cryotherapy.

In addition, curative treatment of actinic keratoses requires a full-thickness necrosis of the epidermis.  Brodland and Roenigk estimate that this depth of necrosis would be unlikely with concentrations of TCA less than 35%.  Therefore, requests for epidermal peels as a treatment of actinic keratoses may actually represent primarily cosmetic procedures and should be carefully evaluated.

Epidermal peels with alpha-hydroxy acids, so-called fruit acids that include glycolic acid and lactic acid, are frequently used for the treatment of active acne.  While low concentrations of glycolic acid can be administered by the patient at home, higher concentrations (50%–70%) are administered in the dermatologist’s office.  Superficial glycolic acid peels are usually done as an adjunct to other comedolytic therapy done in the office.  Typically, patients are treated every two to three weeks on a repeated basis.  Since chemical peeling does not represent a curative therapy, treatments may be continued over the course of years.  Superficial peels for these patients represent a more intense form of therapy, inasmuch as referral to a dermatologist is required. Therefore patients with acne requesting coverage for chemical peels should have failed a trial of topical and oral antibiotic therapy for acne.

A search of the literature was completed through MEDLINE database for the period of January 2005 through July 2007.  No additional published studies were identified that would prompt reconsideration of the policy statement

2009 Update

A search of peer reviewed literature through July 2009 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

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. 

ICD-9 Codes
Refer to the ICD-9-CM manual.
Procedural Codes: 15788, 15789, 15792, 15793
References
  1. Pelner, L., and P.G. Unna.  Pioneer dermatologist and creator of modern dermatopathology.  New York State Journal of Medicine (1971 December 15) 71(24):2895-6.
  2. Brodland, D.G., and R.J. Roenigh.  Trichloroacetic acid chemexfoliation (chemical peel) for extensive premalignant actinic damage of the face and scalp.  Mayo Clinic Proceedings (1988 September) 63(9):887-96.
  3. Morganroth, G.S., Leffell, D.J., et al.  Nonexcisional treatment of benign and premalignant cutaneous lesions.  Clinics in Plastic Surgery (1993 January) 20(1):91-104.
  4. Lawrence N., Cox, S.E., et al.  A comparison of the efficacy and safety of Jessner’s solution and 35% trichloroacetic acid vs. 5% flouracil in the treatment of widespread facial actinic keratosis. Archives of Dermatology (1995 February) 131(2):176-81.
  5. Witheiler, D.D., Lawrence, N., et al.  Long term efficacy and safety of Jessner’s solution and 35% trichloroacetic acid vs. 5% fluorouracil in the treatment of widespread facial actinic keratosis.  Dermatologic Surgery (1997 March) 23(3):191-6.
  6. Wang, C.M.  The effect of glycolic acid on the treatment of acne in Asian skin.  Dermatologic Surgery (1997 January) 2391):23-9.
  7. Ayhan, S., Baran, C.N., et al.  Combined chemical peeling and dermabrasion for deep acne and posttraumatic scars as well as aging face.  Plastic and Reconstructive Surgery (1998) 102(4):1238-46.
  8. Moy, L.S., Kotler, R., et al.  The histologic evaluation of pulsed carbon dioxide laser resurfacing versus phenol chemical peels in vivo.  Dermatologic Surgery (1999 August) 25-(8):597-600.
  9. Rice, P., Brown, R.F., et al.  Dermabrasion—a novel concept in the surgical management of sulfur mustard injuries.  Burns (2000) 26(1):34-40.
  10. Hopkins, J.D., Smith, A.W., et al.  Adjunctive treatment of congenital pigmented nevi with phenol chemical peel.  Plastic Reconstructive Surgery (2000) 105(1):1-11.
  11. Monheit, G.D.  Medium-depth chemical peels.  Dermatology Clinics (2001) 19(3):413-425, vii.
  12. Stone, P.A., and L.G. Lefer.  Modified phenol chemical face peels:  recognizing the role of application techniques.  Clinics in Plastic Surgery (2001 January) 28(1):13-36.
  13. Monheit, G.D.  Medium-depth clinical peels.  Dermatologic Clinics (2001 July) 19(3):413-25.
  14. Al-Waiz, M.M., and A. I. Al-Sharqi.  Medium-depth chemical peels in the treatment of scars in dark-skinned individuals.  Dermatologic Surgery (2002 May) 28(5):383-7.  
  15. P.A. Le Pillouer.  Casanova, Scarring Process after induced dermabrasion.  Wound Repair Regen (2002) 10(2):113-5. 
  16. Chemical Peels.  Chicago, Illinois:  Blue Cross Blue Shield Association Medical Policy Reference Manual (2003 March) Therapy 8.01.16. (Archived)
  17. Wiest, L.  Chemical Peels in aesthetic dermatology.  Hautaret (2004 July) 55(7):611-20.
  18. Briden, M.E.  Alpha-hydroxy acid chemical peeling agents:  case studies and rationale for safe and effective use.  Cutis (2004 February) 73(2 Supplement):18-24.
  19. Solish, N., Raman, M., et al.  A review.  Journal of Cutaneous Medicine and Surgery (2004 March-April) 8(2):77-89.
  20. Halaas, Y.P.  Medium-depth peels.  Facial Plastic Surgical Clinics of North America (2004 August) 12(3):297-303.
  21. Rendon, M.I.  Utilizing combination therapy to optimize melasma outcomes.  Journal of Drugs in Dermatology (2004 September-October) 3(5 Supplement):S27-34.
  22. eMedicine.com – Kuwahara, R.T., Rasberry, R., et al.  Chemical Peels.  eMedicine Continuing Education (2005 January 12).  Available at http://www.emedicine.com (accessed – 2005  March 10).
History
October 2012  Policy returned to active review; policy updated with literature review through May 2012; clinical input reviewed; no change in intent of policy statements; background and Rationale sections rewritten; references 1, 2, and 6-10 added; other references renumbered/removed. 
August 2013 Policy formatting and language revised.  Title changed from "Chemical Peels, Dermabrasion and Microdermabrasion" to "Chemical Peels".  Removed CPT code 17360. 
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Chemical Peels