CurrentEmblemHealthPolicy MG.MM.ME.54a

Chemical Peels

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Clinical coverage criteria for chemical peel procedures, specifying when medium or deep peels are medically necessary and listing limitations/exclusions; applies to EmblemHealth members and treating providers submitting documentation for review.

Policy Summary

PayerEmblemHealth

PolicyChemical Peels

Policy CodePolicy MG.MM.ME.54a

Change TypeAddition — covered indication

Effective Date

Last ReviewMar 13, 2026

Next Review DateMar 13, 2026

Key ActionSubmit clinical documentation demonstrating the member meets criteria to support prior authorization review for medium or deep chemical peels.

SourceLink

POLICY UPDATE CHANGES

Disseminated superficial actinic porokeratosis was added as a covered indication.

>10AK threshold (medium/deep peels)

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CurrentEmblemHealthPolicy MG.MM.ME.54a

Chemical Peels

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Policy Summary

PayerEmblemHealth

PolicyChemical Peels

Policy CodePolicy MG.MM.ME.54a

Change TypeAddition — covered indication

Effective Date

Last ReviewMar 13, 2026

Next Review DateMar 13, 2026

Key ActionSubmit clinical documentation demonstrating the member meets criteria to support prior authorization review for medium or deep chemical peels.

SourceLink

POLICY UPDATE CHANGES

Disseminated superficial actinic porokeratosis was added as a covered indication.

>10AK threshold (medium/deep peels)

Coverage Criteria for Chemical Peels

Medically Necessary Indications

Medium or deep chemical peels are considered medically necessary when ANY of the following conditions are met:

Covered indications: Medium or deep chemical peels are considered medically necessary for > 10 actinic keratoses (or other premalignant skin lesions)>10 actinic keratoses

Used when treating individual lesions is impractical due to number of lesions

Covered indications: Medium or deep chemical peels are considered medically necessary for disseminated superficial actinic porokeratosis (DSAP)

DSAP was added as a covered indication in the Mar 13, 2026 revision

Chemical peels are not considered medically necessary for the treatment of active acne vulgaris due to insufficient evidence of therapeutic value.

Chemical peels are not considered medically necessary when performed for cosmetic purposes, including but not limited to: acne scarring (case‑by‑case review when documentation substantiating medical necessity is submitted), contouring/discoloration/hyperpigmentation (for example, dermatosis papulosa nigra or rosacea), dull complexion, ephelides (freckles), fine lines and wrinkles, lentigines (age/liver spots), melasma, photoaged skin, sebaceous hyperplasia, seborrheic keratoses, and skin roughness.

Use of chemical peels for the cosmetic indications listed above is considered not medically necessary. Providers should note that acne scarring may be reviewed on a case‑by‑case basis if sufficient clinical documentation demonstrating medical necessity is submitted to the plan.

Requests for chemical peels intended primarily for aesthetic improvement (for example to address hyperpigmentation, fine lines, or overall skin appearance) do not meet criteria for medical necessity under this policy.

Procedure and Diagnosis Codes

Procedure CPT CodesCPT

15788	Chemical peel, facial; epidermal.
15789	Chemical peel, facial; dermal.
15792	Chemical peel, nonfacial; epidermal.
15793	Chemical peel, nonfacial; dermal.

ICD-10 DiagnosesICD-10

D48.5	Neoplasm of Uncertain Behavior of Skin.
L56.5	Disseminated Superficial Actinic Porokeratosis.
L57.0	Actinic keratosis.

Actinic keratoses count threshold — inv-06

Threshold> 10 actinic keratoses (AKs) required for medical necessity of medium or deep chemical peels

ApplicationApplies when individual lesion treatment is impractical due to extensiveness of premalignant actinic damage

Covered proceduresMedium or deep chemical peels (see CPT codes 15789, 15793 for dermal peels) when threshold met

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization and Covered Indications

Prior authorization is required for medium or deep chemical peels. Preauthorization review requires submission of clinical documentation demonstrating that the member meets covered indications (for example: > 10 actinic keratoses or disseminated superficial actinic porokeratosis [DSAP], where treating lesions individually is impractical).

Covered indication example: > 10 actinic keratoses (or other premalignant lesions).
Covered indication example: Disseminated superficial actinic porokeratosis (DSAP).

Documentation Required

Clinical Evidence Required

The treating physician or primary care provider must submit clinical evidence that the member meets the criteria for the treatment or procedure. This evidence should be included with the prior authorization request so EmblemHealth can properly review medical necessity.

Background

Chemical peels involve the controlled removal of varying layers of skin using caustic chemical agents. Peels are categorized by depth — commonly described as very superficial, superficial, medium, or deep — and by the agent used (for example, glycolic acid, trichloroacetic acid, phenol, or Jessner solution).

Medium or deep chemical peels may be used to treat extensive premalignant actinic damage when treating individual lesions is impractical; under this policy, they are considered medically necessary for specific indications (see COVERAGE CRITERIA).

Definitions

Chemical peel — inv-12

DefinitionControlled removal of varying layers of the skin using caustic chemical agents, resulting in a thinner, more compact stratum corneum, thicker epidermis, and more uniform melanin distribution

Very superficial peelsExamples: glycolic acid 30–50% (1–2 minutes); Jessner solution (1–3 coats); low concentration resorcinol 20–30% (5–10 minutes)

Superficial peelsExamples: glycolic acid 50–70% (2–5 minutes); pyruvic acid 40–50% (3–5 minutes); Jessner solution (4–10 coats); resorcinol 40–50% (30–60 minutes); TCA 10–30%

Medium peelsExamples: glycolic acid 70% (3–15 minutes); pyruvic acid 60% (3–5 minutes); TCA 35–50%; augmented TCA combinations (eg, CO2 + TCA 35%, Jessner + TCA 35%, glycolic 70% + TCA 35%)

Deep peelsExamples: phenol 88% (Baker-Gordon phenol formula) — used for deepest skin resurfacing