Latest Review Date: January 2024

Category: Surgical

POLICY:

Dermal chemical peels may be considered medically necessary when used to treat extensive actinic keratosis (greater than 10 lesions) when photodynamic therapy (PDT) with topical 5-aminolevulinic acid is not a treatment option due to the presence of hyperkeratotic lesions and the individual is unable to tolerate treatment with topical 5-FU. 

Epidermal chemical peels may be considered medically necessary when used to treat active comedonal acne that has failed a trial of topical and/or oral antibiotic acne therapy. In this setting, epidermal chemical peels with 50-70% alpha-hydroxy acids are used as a comedolytic therapy.

• Up to 8 epidermal (superficial) peels may be considered medically necessary for treatment of comedonal acne.

• Pre-procedural photos must document the presence of active comedonal acne and be submitted for review along with the clinical documentation. Each photo should be labeled with the individual’s name, date and procedure to be performed.
• Photos should include the following:
  • Full-face front
  • Right and left oblique
  • Close-up of regional area
• The active ingredient and strength should be documented for each treatment session as well as any changes noted from previous treatment. 

Epidermal chemical peels with 50 - 70% alpha hydroxy acids as a first-line treatment of active acne are considered not medically necessary.

Subsequent epidermal (superficial) peels (i.e., >8) for treatment of active comedonal acne may be medically necessary with submission of supportive clinical documentation, including pre- and post-procedural photos of previous treatments showing improvement of condition.

• Each photo should be labeled with the individual’s name, date and procedure to be performed.
• Photos should include the following:
  • Full-face front
  • Right and left oblique
  • Close-up of regional area

• The active ingredient and strength should be documented for each treatment session as well as any changes noted from previous treatment. 

Chemical peels performed for photoaged skin, wrinkles or acne scarring are considered not medically necessary and cosmetic.

DESCRIPTION OF PROCEDURE OR SERVICE:

A chemical peel is a controlled removal of various layers of the skin with the use of a chemical agent. The most common use of chemical peeling is the treatment of photoaged skin. Chemical peeling has also been used for other conditions, including actinic keratoses, active acne, and acne scarring.

Chemical Peels

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 the 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 individuals. Potential local complications include scarring, infection, hypopigmentation, hyperpigmentation, activation of herpes simplex, and toxic shock syndrome.

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, the duration of the application, and the number of applications. Possible indications for each type of peel and common chemicals used, as described by Cummings et al (2005) 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 new, erythematous epithelium. Individuals are advised to wait at least 3 months before resuming skincare 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 mid-reticular 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 increase as the strength of the chemicals and the 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 individuals 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 and moderate-to-severe acne. Actinic keratoses are common skin lesions associated with extended exposure to the sun, with an estimated prevalence in the U.S. of 11% to 26%. These lesions are generally considered to be a precursor of squamous cell carcinoma. The risk of progression to invasive squamous cell carcinoma is unclear, but estimates vary from 0.1% to 20%. 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.

Acne vulgaris is the most common skin condition among adolescents, affecting an estimated 80% of teenagers aged 13 to 18 years old. 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.

KEY POINTS:

The literature search for this policy was performed through November 3, 2023.

Summary of Evidence

For individuals who have actinic keratoses who receive chemical peels, the evidence consists of a systematic review involving 8 studies - 4 randomized controlled trials (RCTs), 2 non-randomized controlled trials, and 2 single-arm studies. Relevant outcomes are symptoms, morbid events, quality of life, and treatment-related morbidity. Data analysis and interpretation of results were challenged by the high risk of bias of the primary studies, their imprecision, the variability of their peeling application protocols, and their focus on short-term clearance rates. Additional controlled studies, preferably randomized, are needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have moderate-to-severe active acne who receive epidermal chemical peels, the evidence includes an RCT. Relevant outcomes are symptoms, morbid events, quality of life, and treatment-related morbidity. Results from the single, small, randomized, placebo-controlled, split-faced trial found greater efficacy with active treatment than with placebo. However, no studies were identified comparing chemical peel agents with conventional acne treatment. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Practice Guidelines and Position Statements

American Academy of Dermatology

In 2016, the American Academy of Dermatology (AAD) published guidelines on the management of acne vulgaris, which give a B recommendation based on level II and III evidence for the use of chemical peels for acne, with the following statement on chemical peels:

“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 noninflammatory (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.”

In 2021, the AAD published guidelines on the management of actinic keratosis, which gave a conditional recommendation based on moderate quality of evidence for the use of specific chemical peels for actinic keratosis. The recommendation stated: "For patients with AKs [actinic keratosis], we conditionally recommend treatment with ALA [aminolevulinic acid]-red light PDT [photodynamic therapy] over trichloroacetic acid peel."

American Society for Dermatologic Surgery

In 2017, The American Society for Dermatologic Surgery published recommendations on the use of several skin treatments following a course of isotretinoin, a treatment for severe cystic acne. Previously, several cosmetic skin treatments, including chemical peels, were discouraged for 6 months after the use of isotretinoin. These 2017 guidelines evaluated various treatments in the context of scarring and found that superficial chemical peels were safe as a treatment either concurrent with isotretinoin or within 6 months of its discontinuation. The lack of data on medium or deep chemical peels did not permit the Society to make a recommendation on those treatments.

U.S. Preventive Services Task Force Recommendations

Not Applicable.

KEY WORDS:

Chemical peel, skin peel, actinic keratoses, active acne, premalignant skin lesions, comedonal acne, epidermal peel, superficial peel, alpha hydroxy acids, comedolytic therapy

APPROVED BY GOVERNING BODIES:

FDA clearance or approval may not be relevant for the chemical agents used in peeling because they are prepared in-office, may have pre-dated FDA approval and/or may be considered cosmetic ingredients.

BENEFIT APPLICATION:

Coverage is subject to the member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP: Special benefit consideration may apply.  Refer to the member’s benefit plan.

CURRENT CODING: 

CPT code:

REFERENCES:

1. Alfaro OL, Alcala PD, Navarrete FG, et al. Effectiveness of Jessner's solution plus 35% trichloroacetic acid versus 5% 5-fluorouracil on multiple facial actinic keratosis. Dermatol Rev Mex. 2012;56:38-46.
2. 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.
3. Cummings CW, Haughey BH, Thomas JR, et al. Otolaryngology: Head and Neck Surgery, 4th edition, 2005. Mosby, Chapter 29, pp. 700-711.
4. Di Nuzzo S, Cortelazzi C, Boccaletti V, et al. Comparative study of trichloroacetic acid vs. photodynamic therapy with topical 5-aminolevulinic acid for actinic keratosis of the scalp. Photodermatol Photoimmunol Photomed. Sep 2015; 31(5): 233-238.
5. Eisen DB, Asgari MM, Bennett DD, et al. Guidelines of care for the management of actinic keratosis. J Am Acad Dermatol. Oct 2021; 85(4): e209-e233.
6. Habif TP. Clinical Dermatology 5th Edition. Philadelphia, PA: Mosby/Elsevier; 2010.
7. Holzer G, Pinkowicz A, Radakovic S, et al. Randomized controlled trial comparing 35% trichloroacetic acid peel and 5-aminolaevulinic acid photodynamic therapy for treating multiple actinic keratosis. Br J Dermatol. May 2017; 176(5): 1155-1161.
8. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
9. 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 2014; 40(3):314-322.
10. 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, April 2009; 60(4): 615-625.
11. 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.
12. Marrero GM, Katz BE. The new fluor-hydroxy pulse peel. A combination of 5-fluorouracil and glycolic acid. Dermatol Surg. Sep 1998; 24(9): 973-978.
13. 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.
14. Purdy S, de Berker D. Acne vulgaris. BMJ Clin Evid. Jan 05 2011;2011.
15. Sandoval Osses M, Garcia-Huidobro Ramirez I, Molgo Novell M. Safety and effectiveness of the association of 5-fluorouracil and glycolic acid peeling for the treatment of multiple actinic keratoses. Piel. 2010;25: 4-8.
16. Steeb T, Koch EAT, Wessely A, et al. Chemical peelings for the treatment of actinic keratosis: a systematic review and meta-analysis. J Eur Acad Dermatol Venereol. Mar 2021; 35(3): 641-649.
17. Sumita JM, Miot HA, Soares JLM, et al. Tretinoin (0.05% cream vs. 5% peel) for photoaging and field cancerization of the forearms: randomized, evaluator-blinded, clinical trial. J Eur Acad Dermatol Venereol. Oct 2018; 32(10): 1819-1826.
18. Waldman, et al. ASDS Guidelines Task Force: Consensus Recommendations Regarding the Safety of Lasers, Dermabrasion, Chemical Peels, Energy Devices, and Skin Surgery During and After isotretinoin Use. Dermatol Surg. Oct 2017;43(10):1249-1262.
19. Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. May 2016;74(5):945-973 e933.

POLICY HISTORY:

Medical Policy Group, 1996

TEC, July 1998

Medical Policy Group, 2000

Medical Policy Group, April 2002

Medical Policy Group, June 2002

Medical Policy Administration Committee, June 2002

Available for comment June 17-July 31, 2002

Medical Policy Group, June 2004 (2)

Medical Policy Group, July 2006 (1)

Medical Policy Group, July 2008 (1)

Medical Policy Group, July 2010 (1): Description, Key Points and Governing Bodies updated, policy statement unchanged.

Medical Policy Group, July 2011 (1): Added criteria for epidermal chemical peels for active acne to policy from DORS page; Added acne scarring to non-covered statement; Removed “for Actinic Keratosis” from title; Separated chemical peels into epidermal and dermal with appropriate criteria to match; Updated Key Points, Key Words, Coding and References related to “active acne”

Medical Policy Administration Committee, August 2011

Available for comment September 2 through October 17, 2011

Medical Policy Group, July 2012 (4): Updated Key Points and References. No changes to the policy statement.

Medical Policy Panel, July 2013

Medical Policy Group, July 2013 (3):  Updated Key Points and References; no change in policy statement.

Medical Policy Panel, July 2014

Medical Policy Group, July 2014 (3):  2014 Updates to Description, Key Points & References; no change in policy statement; removed 2011 and older policy statements.

Medical Policy Panel, July 2015

Medical Policy Group, July 2015 (2): 2015 Updates to Key Points and Key Words; no change to policy statement.

Medical Policy Group, July 2016 (7): 2016 Updates to Key Words. Policy statement updated- added new criteria for use of epidermal (superficial) peels for treatment of active comedonal acne; added limit of up to 8 epidermal (superficial) peels and added criteria for subsequent epidermal (superficial) peels (i.e., >8) for treatment of active comedonal acne.

Medical Policy Administration Committee, August 2016

Available for comment August 1 through September 14, 2016

Medical Policy Panel, December 2016

Medical Policy Group, December 2016 (7): 2016 Updates to Description, Key Points and References. No change to policy statement.

Medical Policy Panel, December 2017

Medical Policy Group, December 2017 (7): 2017 Updates to Key Points and References. No change to policy statement.

Medical Policy Panel, December 2018

Medical Policy Group, January 2019 (7): Updates to Key Points. No change in policy statement.

Medical Policy Panel, December 2019

Medical Policy Group, December 2019 (5): Updates to Description and Key Points. No change to Policy Statement.

Medical Policy Panel, December 2020

Medical Policy Group, January 2021 (5): Updates to Description, Key Points, and References. No change to Policy Statement.

Medical Policy Panel, December 2021

Medical Policy Group, December 2021 (5): Updates to Description, Key Points, and References. No change to Policy Statement.

Medical Policy Panel, December 2022

Medical Policy Group, December 2022 (5): Updates to Description and Key Points. Added CPT code 17360 to Current Coding section effective 1/1/23. Policy Statement updated to replace the word “patient” with the word “individual’s.” No change to policy intent.

Medical Policy Panel, December 2023

Medical Policy Group, January 2024 (9): Updates Key Points, Practice Guidelines and Position Statements, Benefit Application and References.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.