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Date Printed: October 20, 2017: 02:05 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-10000-08

Original Effective Date: 05/15/02

Reviewed: 02/23/17

Revised: 03/15/17

Subject: Dermabrasion,Chemical Peels, Salabrasion, and Acne Surgery

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Dermabrasion: Dermabrasion is a method of controlled surgical scraping of the skin. Using a diamond fraise (similar to a small electric sanding drill tip) spun at high speeds, it is drawn over the skin surface, removing the entire epidermis and upper dermis. Dermabrasion is typically limited to the face and has been found to be useful for treating actinic keratoses. Facial chemical peeling is often used in conjunction with dermabrasion. The main advantage of dermabrasion over the chemical peel is the absence of severe depigmentation.

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 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.

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. 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. 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 1 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.

Salabrasion: A method of removing tattoos from the skin where moist gauze pads saturated with sodium chloride are used to abrade the tattooed area by rubbing.

Acne Surgery: Acne surgery includes the opening up of comedones (blackheads and whiteheads) and pimples using a needle or small pointed blade and the expressing of the lesions with an extractor. Acne surgery may include such treatments as extraction of comedonal contents, incision and drainage of pustules and cysts, and excision of cysts. Treatment of active acne is distinct from the treatment of acne scarring which may occur from tissue damage after inflammation subsides. The treatment of acne scarring is considered cosmetic in nature and therefore is not a contract benefit.

POSITION STATEMENT:

Dermabrasion or dermal chemical peels meet the definition of medical necessity for treatment of actinic keratosis when ALL of the following criteria are met:

Epidermal chemical peels used to treat members with active acne that has failed a trial of topical or oral antibiotic acne therapy meet the definition of medical necessity. In this setting, superficial chemical peels with 40% to 70% alpha hydroxy acids are used as a comedolytic therapy.

Acne surgery (marsupialization, opening or removal of multiple milia, comedones, cysts, pustules) meets the definition of medical necessity for ONE of the following situations:

The following therapies are considered experimental or investigational for the treatment of active acne:

The evidence is insufficient to determine the effects of the technology on health outcomes.

The following therapies are considered cosmetic and do not meet the definition of medical necessity for the treatment of acne scarring and other untoward cosmetic effects of acne, as the sole purpose is to improve appearance:

Dermabrasion, chemical peels or salabrasion are considered cosmetic and do not meet the definition of medical necessity for any of the following indications, as the sole purpose is to improve appearance (the list is not all-inclusive):

BILLING/CODING INFORMATION:

CPT Coding:

10040

Acne surgery (e.g., marsupialization, opening or removal of multiple milia, comedones, cysts, pustules)

15780

Dermabrasion; total face (e.g., for acne scarring, fine wrinkling, rhytids, general keratosis)

15781

Dermabrasion; segmental, face

15782

Dermabrasion; regional, other than face

15783

Dermabrasion; superficial, any site, (e.g., tattoo removal)

15788

Chemical peel, facial; epidermal

15789

Chemical peel, facial; dermal

15792

Chemical peel, nonfacial; epidermal

15793

Chemical peel; nonfacial; dermal

17110

Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions (not covered for acne treatment)

17111

Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions (not covered for acne treatment)

17340

Cryotherapy (CO2 slush, liquid N2) for acne (non-covered)

17360

Chemical exfoliation for acne (e.g., acne paste, acid) (non-covered)

96567

Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (e.g. lip) by activation of photosensitive drug(s), each phototherapy exposure session (not covered for acne treatment)

96570

Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug(s), first 30 minutes (not covered for acne treatment)

96571

Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug(s), each additional 15 minutes (not covered for acne treatment)

96900

Actinotherapy (ultraviolet light) (not covered for acne treatment)

HCPCS Coding:

E0691

Ultraviolet light therapy system, includes bulbs/lamps, timer, and eye protection; treatment area 2 sq. ft. or less (not covered for acne treatment)

E0692

Ultraviolet light therapy system panel, includes bulbs/lamps, timer, and eye protection; 4 ft. panel (not covered for acne treatment)

E0693

Ultraviolet light therapy system panel, includes bulbs/lamps, timer, and eye protection; 6 ft. panel (not covered for acne treatment)

E0694

Ultraviolet multidirectional light therapy system in 6 ft. cabinet, includes bulbs/lamps, timer, and eye protection (not covered for acne treatment)

ICD-10 Diagnoses Codes That Support Medical Necessity for CPT codes 15780, 15781, 15782, 15783, 15789, & 15793:

D48.5

Neoplasm of uncertain behavior of skin

L57.0

Actinic keratosis

ICD-10 Diagnoses Codes That Support Medical Necessity for CPT codes 10040, 15788 & 15792:

L70.0 – L70.9

Acne

REIMBURSEMENT INFORMATION:

None applicable.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Treatment of Actinic Keratosis (250.4) located at cms.gov.

DEFINITIONS:

5-fluorouracil (5-FU): FDA- approved, 5-FU inhibits thymidylate synthetase and causes cell death in actively proliferating cells.

Actinic keratosis: a sharply outlined, red or skin-colored, flat or elevated, verrucous or keratotic growth, which may develop into a cutaneous horn, and may give rise to a squamous cell carcinoma.

Imiquimod: FDA-approved, imiquimod stimulates the immune system to produce interferon, a chemical that destroys cancerous and precancerous cells.

RELATED GUIDELINES:

Contraceptive Drugs, 09-J0000-60

Psoralens with Ultraviolet A (PUVA), 02-10000-16

Reconstructive Surgery/Cosmetic Surgery, 02-12000-01

OTHER:

None applicable.

REFERENCES:

  1. Blue Cross Blue Shield Association Medical Policy Reference Manual-8.01.16, Chemical Peels, 12/16.
  2. Centers for Medicare & Medicaid Services (CMS), NCD for Treatment of Actinic Keratosis (Aks) (250.4), 11/01; accessed at cms.gov.
  3. ClinicalTrials.gov, Hyperbaric Therapy and Deep Chemical Peeling, sponsored by Assaf-Harofeh Medical Center, accessed 03/29/10.
  4. ClinicalTrials.gov, Interest of the Dermabrasion by Laser Erbium in the Treatment of the Vitiligo, sponsored by Centre Hospitalier Universitaire de Nice, accessed 03/29/10.
  5. ClinicalTrials.gov, Randomized Clinical Trial Comparing Treatment of Tretinoin or Superficial Dermabrasion for Stretch Marks, sponsored by Brazilian Center for Studies in Dermatology, accessed 03/29/10.
  6. ClinicalTrials.gov, Treatment of Melasma with Jessner’s Solution vs. Trichloroacetic Acid, sponsored by Emory University, accessed 03/29/10.
  7. Coleman WP, Yarborough JM, Mandy SH, Dermabrasion for Prophylaxis and Treatment of Actinic Keratoses, Dermatologic Surgery, Vol 22, Issue 1, pgs 17-21, 06/28/08.
  8. 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.
  9. De Berker D, McGregor JM, Hughes BR, et al, Guidelines for the Management of Actinic Keratoses, National Guideline Clearinghouse, 2007 accessed at guideline.gov 02/23/12.
  10. Guidelines for the Management of Actinic Keratoses, Guideline Subcommittee of the European Dermatology Forum, accessed at euroderm.org 03/30/10.
  11. Guidelines of care for chemical peeling; Journal of the American Academy of Dermatology, Vol 33, Number 3, pp 497-503 (09/95).
  12. Habif: Clinical Dermatology, 3rd Edition, pp 168, 602, 648, 833. (Copyright 1996 Mosby-Year Book, Inc.).
  13. Kaminaka C, Yamamoto Y, et al, Phenol Peels as a Novel Therapeutic Approach for Actinic Keratosis and Bowen Disease: Prospective Pilot Trail with Assessment of Clinical, Histologic, and Immunohistochemical Correlations, Journal of the American Academy of Dermatology, Vol. 60, Issue 4, pages 615-625, April 2009.
  14. National Cancer Institute: PDQ® Skin Cancer Treatment. Bethesda, MD: National Cancer Institute. Accessed at cancer.gov/cancertopics/pdq/treatment/skin/healthprofessional;02/22/12.
  15. National Comprehensive Cancer Network (NCCN), Clinical Practice Guidelines in Oncology- Squamous Cell Skin Cancer, Version l.2017.
  16. Ogden S, Griffiths TW, A Review of Minimally Invasive Cosmetic Procedures, The British Journal of Dermatology, 12/08/08.
  17. Strauss JS, Krowchuk DP, Leyden JJ, et al, Guidelines of Care for Acne Vulgaris Management, J Am Acad Dermatol 2007; 56: 651-63.
  18. 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.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 02/23/17.

GUIDELINE UPDATE INFORMATION:

04/25/02

New Medical Coverage Guideline.

05/15/02

Reviewed and reformatted; additional procedure codes included.

06/15/04

Scheduled review and revision to guideline; consisting of updated references and various changes.

01/01/06

HCPCS update; deleted 15810, 15811.

11/15/06

Revision of guideline consisting of the addition of 17340.

09/15/07

Review, coverage statement maintained, guideline reformatted, references updated.

08/15/09

Review, position statements revised, description section and references updated.

01/01/10

Annual HCPCS coding update: revised descriptor for code 15787.

05/15/10

Annual review: position statements maintained and references updated.

10/15/10

Revision; related ICD-10 codes added.

04/15/12

Annual review; position statement maintained, formatting changes, and references updated.

05/11/14

Revision: Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

10/01/16

Revision; coding section updated; formatting changes.

03/15/17

Revision; Updates to actinic keratosis position statement, new epidermal chemical peels position statement added; acne surgery and nonpharmaceutical treatments incorporated from the Acne Treatments MCG (Acne Treatments MCG archived effective 3/15/17); MCG title, description, coding, and references updated.

Date Printed: October 20, 2017: 02:05 PM