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Clinical Policy Bulletin:
Dermabrasion, Chemical Peels, and Acne Surgery
Number: 0251


Policy

Dermabrasion (see also CPB 031 - Cosmetic Surgery )

Aetna considers dermabrasion using the conventional method of controlled surgical scraping (dermaplaning) or carbon dioxide (CO2) laser for removal of superficial basal cell carcinomas and pre-cancerous actinic keratoses medically necessary when both of the following criteria are met:

  1. Conventional methods of removal such as cryotherapy, curettage, and excision, are impractical due to the number and distribution of the lesions; and
  2. The member has failed a trial of 5-fluorouracil (5-FU) (Efudex) or imiquimod (Aldara), unless contraindicated.

Aetna considers dermabrasion for removal of acne scars to be cosmetic.  Dermabrasion and microdermabrasion is considered experimental and investigational in treating active acne because it has been shown to increase inflammation associated with active acne. 

Aetna considers dermabrasion experimental and investigational for the treatment of melasma and all other indications because its effectiveness for these indications has not been established.

Chemical Peel (see also CPB 031 - Cosmetic Surgery )

Aetna considers medium and deep chemical peels for actinic keratoses and other pre-malignant skin lesions medically necessary when members have 15 or more lesions, such that it becomes impractical to treat each lesion individually, and they have failed to adequately respond to treatment with topical 5-FU or imiquimod, unless contraindicated.   Aetna considers chemical peels not medically necessary for the treatment of non-malignant (simple) lesions.

Aetna considers chemical peels for active acne experimental and investigational because they have not been shown to be effective for that indication.

Aetna considers chemical peels for acne scarring, melasma, skin wrinkling or lentigenes to be cosmetic.

Aetna considers chemical peels experimental and investigational for all other indications.

Acne Surgery

Aetna considers acne surgery such as marsupialization, opening or removal of multiple milia, comedones, cysts, pustules medically necessary for the treatment of acne.

Aetna considers cryoslush therapy (solid CO2 mixed with acetone) and liquid nitrogen therapy experimental and investigational for acne.



Background

Dermabrasion

Dermabrasion is a dermatologic procedure that exerts its therapeutic effect by removing the epidermis and superficial dermis, allowing re-epithelialization from the underlying skin to occur.  Therefore the technique is best used for superficial lesions of the face (Fitzpatrick, et al., 1993). 

Standard dermabrasion uses a wire brush or diamond fraise (a stainless steel wheel on which diamond chips have been bonded) abraders to plane the skin whereas laser dermabrasion involves use of the argon laser, ultrapulse carbon dioxide (CO2) laser, or flashlamp-pumped pulsed dye laser to resurface the entire face, and has been used as an alternative to standard dermabrasion in treating patients with inactive acne with disfiguring scarring (Wheeland, 1995; Alster & McMeckin, 1996; Alster & West, 1996; Ruback & Schoenrock, 1997; Aronsson, et al., 1997; Fulton, 1996).  Manufacturers of lasers cleared by the Food and Drug Administration for general skin resurfacing include Laser Industries, Coherent, Tissue Technologies, and Heraeus Surgical.

Dermabrasion is contraindicated in patients with active acne, as it may exacerbate skin inflammation (AAD, 1994; Arnold, et al., 1990).  Acne is active when inflammation is present, and is treated with oral and topical antibiotics and retinoids (such as isotrentoin (Accutane) or retinoic acid (Retin-A).  Dermabrasion conducted within 6 months of isotrentoin treatment has been associated with increased scarring (Fitzpatrick, et al., 1993; AAD, 1994).  Coverage is not provided for dermabrasion for inactive acne (such as in removal of scars from chronic cystic acne) as dermabrasion is considered a cosmetic procedure for this indication.

Because of a lack of evidence of safety and effectiveness, dermabrasion of active acne is considered investigational.  Dermabrasion for post-acne scarring is considered a cosmetic procedure.

Chemical Peels

Chemical peels can be classified according to the type of "wounding" agent used and targeted depth of exfoliation (i.e., superficial, medium, deep).  Chemicals most often used in superficial peels are: 10 - 35 % trichloroacetic acid (TCA), resorcin, Jessner's solution, retin-A, 5-FU, azelaic acid and alpha hydroxy acids (glycolic and lactic acid).  For medium peels 50 % TCA is used or lower concentrations of TCA in combination with Jessner's solution, 5-FU or carbon dioxide cryotherapy.  Baker's phenol or a 50 - 70 % solution of TCA are used for deep peels.  There is a paucity of data in the literature which compares the effectiveness of the various chemicals used in chemical peels.

Chemical peeling is a long-standing and accepted dermatologic technique.  However, clinical studies comparing the various types of chemical peels, and comparing chemical peels to other forms of therapy are unavailable.  The main coverage issue regarding the technique is the determination of whether the chemical peel is primarily cosmetic in nature.  Actinic keratoses are pre-malignant lesions and the medical necessity for their destruction/removal is not questioned.  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 (1993) suggested that patients with less than 10 actinic keratoses should be treated with cryotherapy.

Additionally, curative treatment of actinic keratoses requires a full thickness necrosis of the epidermis.  Brodland (1988) estimated that this depth of necrosis would be unlikely with concentrations of TCA less than 35 %.  Therefore, coverage requests for superficial chemical peels as a treatment of actinic keratoses may actually represent primarily cosmetic procedures and should be carefully evaluated. 

Currently, Aetna policy indicates that a variety of treatments for active acne are medically necessary (i.e., antibiotic therapy) but that treatment of end stage acne scarring is considered cosmetic.  The same policy can be applied to chemical peels.  Those chemical peels designed to treat end stage scars would be considered cosmetic.  

Superficial chemical peels with alpha-hydroxy acids, so called fruit acids which include glycolic acid and lactic acid, have been used for the treatment of acne.  While low concentrations of glycolic acid can be administered by the patient at home, higher concentrations (50 - 70%) are administered in the office. 

Guidelines from the American Academy of Dermatology observe that both glycolic acid-based and salicylic acid-based peeling preparations have been used in the treatment of acne (Strauss, et al., 2007). The guidelines state: "There is very little evidence from clinical trials published in the peer-reviewed literature supporting the efficacy of peeling regimens. Further research on the use of peeling in the treatment of acne needs to be conducted in order to establish best practices for this modality."

Acne Surgery

The American Academy of Dermatology found limited evidence published in peer reviewed medical literature that addresses the efficacy of comedo removal for the treatment of acne, despite its long-standing clinical use (Strauss, et al., 2007). The guidelines concluded, however, that "[i]t is ... the opinion of the work group that comedo removal may be helpful in the management of comedones resistant to other therapies. Also, while it cannot affect the clinical course of the disease, it can improve the patient’s appearance, which may positively impact compliance with the treatment program."

The guidelines make no mention of the use of liquid nitrogen or cryoslush in the treatment of acne (Strauss, et al., 2007).
 
CPT Codes / HCPCS Codes / ICD-9 Codes
Dermabrasion:
CPT codes covered if selection criteria are met:
15780
15781
15782
15783
ICD-9 codes covered if selection criteria are met:
173.0 - 173.9 Basal cell carcinoma
702.0 Actinic keratosis
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
706.0 Acne varioliformis
706.1 Other acne
709.00 - 709.09 Dyschromia
709.2 Scar conditions and fibrosis of skin
Chemical peel, dermal:
CPT codes covered if selection criteria are met:
15789
15793
ICD-9 codes covered if selection criteria are met:
173.0 - 173.9 Basal cell carcinoma
702.0 Actinic keratosis
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
216.0 - 216.9 Benign neoplasm of skin
706.0 Acne varioliformis
706.1 Other acne
709.09 Other dyschromia
Chemical peel, epidermal:
CPT codes not covered for indications listed in the CPB:
15788
15792
17360
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
701.8 Other specified hypertrophic and atrophic conditions of skin
706.0 Acne varioliformis
706.1 Other acne
709.2 Scar conditions and fibrosis of skin
709.09 Other dyschromia
Acne surgery:
CPT codes covered if selection criteria are met:
10040
ICD-9 codes covered if selection criteria are met:
695.3 Rosacea [acute]
706.0 Acne varioliformis
706.1 Other acne
706.2 Sebaceous cyst [due to acne]
Cryoslush therapy:
CPT codes not covered for indications listed in the CPB:
17340
ICD-9 codes not covered for indications listed in the CPB:
695.3 Rosacea
706.0 Acne varioliformis
706.1 Other acne
706.2 Sebaceous cyst
Other CPT codes related to the CPB:
17000 - 17250
17260 - 17286


The above policy is based on the following references:

Dermabrasion

  1. Rice P, Brown RF, Lam DG, et al. Dermabrasion -- a novel concept in the surgical management of sulphur mustard injuries. Burns. 2000;26(1):34-40.
  2. Hopkins JD, Smith AW, Jackson IT. Adjunctive treatment of congenital pigmented nevi with phenol chemical peel. Plast Reconstr Surg. 2000;105(1):1-11.
  3. Jordan R, Cummins C, Burls A. Laser resurfacing of the skin for the improvement of facial acne scarring. DPHE Report No. 11. Birmingham:, UK: West Midlands Health Technology Assessment Collaboration, Department of Public Health and Epidemiology, University of Birmingham (WMHTAC); 1998.
  4. Jordan R, Cummins C, Burls A. Laser resurfacing of the skin for the improvement of facial acne scarring: A systematic review of the evidence. Br J Dermatol. 2000;142(3):413-423.
  5. Solish N, Raman M, Pollack SV. Approaches to acne scarring: A review. J Cutan Med Surg. 1998;2 Suppl 3:24-32.
  6. Ayhan S, Baran CN, Yavuzer R, et al. Combined chemical peeling and dermabrasion for deep acne and posttraumatic scars as well as aging face. Plast Reconstr Surg. 1998;102(4):1238-1246.
  7. Chiarello SE. CO2 laser for actinically damaged skin. Dermatol Surg. 1998;24(8):933-934.
  8. Grevelink JM, White VR. Concurrent use of laser skin resurfacing and punch excision in the treatment of facial acne scarring. Dermatol Surg. 1998;24(5):527-530.
  9. Weinstein C. Carbon dioxide laser resurfacing. Long-term follow-up in 2123 patients. Clin Plast Surg. 1998;25(1):109-130.
  10. Baker TM. Dermabrasion. As a complement to aesthetic surgery. Clin Plast Surg. 1998;25(1):81-88.
  11. Orentreich N, Orentreich DS. Dermabrasion. As a complement to dermatology. Clin Plast Surg. 1998;25(1):63-80.
  12. Matarasso SL, Hanke CW, Alster TS. Cutaneous resurfacing. Dermatol Clin. 1997;15(4):569-582.
  13. Barnaby JW, Styles AR, Cockerell CJ. Actinic keratoses. Differential diagnosis and treatment. Drugs Aging. 1997;11(3):186-205.
  14. West TB. Laser resurfacing of atrophic scars. Dermatol Clin. 1997;15(3):449-457.
  15. Achauer BM. Lasers in plastic surgery: Current practice. Plast Reconstr Surg. 1997;99(5):1442-1450.
  16. Mandy SH. Dermabrasion. Semin Cutan Med Surg. 1996;15(3):162-169.
  17. Coleman WP 3rd, Yarborough JM, Mandy SH. Dermabrasion for prophylaxis and treatment of actinic keratoses. Dermatol Surg. 1996;22(1):17-21.
  18. Le Pillouer PA, Casanova D. Scarring process after induced dermabrasion. Wound Repair Regen. 2002;10(2):113-115.
  19. Hruza GJ.  Dermabrasion.  Facial Plast Surg Clin North Am. 2001;9(2):267-281, ix.
  20. Helfand M, Gorman AK, Mahon S, et al.  Actinic keratosis. Final Report. Evidence-Based Practice Centers.  Submitted to the Agency for Healthcare Research and Quality under contract 290-97-0018, task order no. 6.  Portland, OR: Oregon Health & Science University Evidence-Based Practice Center; May 19, 2001. Available at:  http://www.cms.gov/coverage/download/8b3-t3.pdf. Accessed October 10, 2002.
  21. Jordan RE, Cummins CL, Burls AJE, Seukeran DC. Laser resurfacing for facial acne scars. Cochrane Database Syst Rev. 2000;(3):CD001866.
  22. Gupta AK, Inniss K, Wainwright R, et al. Interventions for actinic keratoses (Protocol for Cochrane Review). Cochrane Database Syst Rev. 2003;(4):CD004415.
  23. Victor FC, Gelber J, Rao B. Melasma: A review. J Cutan Med Surg. 2004;8(2):97-102.
  24. Samuel M, Brooke RCC, Hollis S, Griffiths CEM. Interventions for photodamaged skin. Cochrane Database Syst Rev. 2005;(1):CD001782.
  25. Grimes PE. Microdermabrasion. Dermatol Surg. 2005;31(9 Pt 2):1160-1165; discussion 1165.
  26. Bhalla M, Thami GP. Microdermabrasion: Reappraisal and brief review of literature. Dermatol Surg. 2006;32(6):809-814.

Chemical Peel

  1. Gutling M. Chemical peel--current possibilities and limits. Ther Umsch. 1999;56(4):182-187.
  2. Godin DA, Graham HD 3rd. Chemical peels. J La State Med Soc. 1998;150(11):513-520.
  3. Demas PN, Bridenstine JB, Braun TW. Pharmacology of agents used in the management of patients having skin resurfacing. J Oral Maxillofac Surg. 1997;55(11):1255-1258.
  4. Giese SY, McKinney P, Roth SI, Zukowski M. The effect of chemosurgical peels and dermabrasion on dermal elastic tissue. Plast Reconstr Surg. 1997;100(2):489-500.
  5. Steinsapir KD. The chemical peel. Int Ophthalmol Clin. 1997;37(3):81-96.
  6. Rubin MG. A peeler's thoughts on skin improvement with chemical peels and laser resurfacing. Clin Plast Surg. 1997;24(2):407-409.
  7. Fulton JE Jr. Dermabrasion, chemabrasion, and laserabrasion. Historical perspectives, modern dermabrasion techniques, and future trends. Dermatol Surg. 1996;22(7):619-628.
  8. Branham GH, Thomas JR. Rejuvenation of the skin surface: Chemical peel and dermabrasion. Facial Plast Surg. 1996;12(2):125-133.
  9. Roenigk RK, Brodland DG. A primer of facial chemical peel. Dermatol Clin. 1993;11(2):349-359.
  10. Morganroth GS, Leffell DJ. Nonexcisional treatment of benign and premalignant cutaneous lesions. Clin Plast Surg. 1993;20:91-104.
  11. Van Scott EJ, Yu RJ. Alpha hydroxy acids: Procedures for use in clinical practice. Cutis. 1989;43:222-228.
  12. Humphreys TR, Werth V, Dzubow L, Kligman A. Treatment of photodamaged skin with trichloroacetic acid and topical tretinoin. J Am Acad Dermatol. 1996;34(4):638-644.
  13. Tse Y, Ostad A, Lee HS, et al. A clinical and histologic evaluation of two medium-depth peels. Glycolic acid versus Jessner's trichloroacetic acid. Dermatol Surg. 1996;22(9):781-786.
  14. Witheiler DD, Lawrence N, Cox SE, 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 keratoses. Dermatol Surg. 1997;23(3):191-196.
  15. Brodland DG, Roenigk RK. Tricholoroacetic acid chemexfoliation (chemical peel) for extensive premalignant actinic damage of the face and scalp. Mayo Clin Proceed. 1988;63(9):887-896.
  16. No authors listed. TCA chemical peel found effective in treating premalignant skin lesions. Oncology (Huntingt). 1992;6(7):87-88.
  17. Jerant AF, Johnson JT, Sheridan CD, Caffrey TJ. Early detection and treatment of skin cancer. Am Fam Physician. 2000;62(2):357-368, 375-376, 381-382.
  18. Monheit GD. Medium-depth chemical peels. Dermatol Clin. 2001;19(3):413-425, vii.
  19. Gupta AK, Inniss K, Wainwright R, et al. Interventions for actinic keratoses (Protocol for Cochrane Review). Cochrane Database Syst Rev. 2003;(4):CD004415.
  20. Khunger N, Sarkar R, Jain RK. Tretinoin peels versus glycolic acid peels in the treatment of Melasma in dark-skinned patients. Dermatol Surg. 2004;30(5):756-760; discussion 760.
  21. Samuel M, Brooke RCC, Hollis S, Griffiths CEM. Interventions for photodamaged skin. Cochrane Database Syst Rev. 2005;(1):CD001782. 
  22. Montemarano AD. Melasma. eMedicine Dermatology Topic 260. Omaha, NE: eMedicine.com; updated June 25, 2003. Available at: http://www.emedicine.com/derm/topic260.htm. Accessed April 22, 2005.
  23. Perras C. Imiquimod 5% cream for actinic keratosis. Issues in Emerging Health Technologies. Issue 61. Ottawa, ON: Canadian Coordinating Office for Health Technology Assessment (CCOHTA); 2004.
  24. Lee SH, Huh CH, Park KC, Youn SW. Effects of repetitive superficial chemical peels on facial sebum secretion in acne patients. J Eur Acad Dermatol Venereol. 2006;20(8):964-968. 
  25. Strauss JS, Krowchuk DP, Leyden JJ, et al. American Academy of Dermatology. Guidelines of care for acne vulgaris management.  J Am Acad Dermatol. 2007;56-651-653. Available at: http://www.aad.org/NR/rdonlyres/8D4D2DDB-7176-4202-808E-28D67334B3E4/0/AcneVulgaris.pdf. Accessed December 18, 2007.

Acne Surgery, Liquid Nitrogen and Cryoslush

  1. Goette DK. Liquid nitrogen in the treatment of acne vulgaris: A comparative study. South Med J. 1973;66(10):1131-1132.
  2. Kaminsky A. Less common methods to treat acne. Dermatololgy. 2003;206:68-73.
  3. Frank SB. An update on acne vulgaris. Int J Dermatol. 1977;16(5):409-412.
  4. Landow K. Dispelling myths about acne. Postgrad Med. 1997;102(2):94-104.
  5. Kaya TI, Tursen U, Kokturk A, Ikizoglu G. An effective extraction technique for the treatment of closed macrocomedones. Dermatol Surg. 2003;29(7):741-744.
  6. Weinrauch L, Peled I, Hacham-Zadeh S, Wexler MR. Surgical treatment of severe acne conglobata. J Dermatol Surg Oncol. 1981;7(6):492-494.
  7. Shalita AR. Surgical procedures for the treatment of acne vulgaris. J Dermatol Surg. 1975;1(3):46-48.
  8. Strauss JS, Krowchuk DP, Leyden JJ, et al. American Academy of Dermatology. Guidelines of care for acne vulgaris management.  J Am Acad Dermatol. 2007;56-651-653. Available at: http://www.aad.org/NR/rdonlyres/8D4D2DDB-7176-4202-808E-28D67334B3E4/0/AcneVulgaris.pdf. Accessed May 7, 2007.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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