Coverage Policy Manual
Policy #: 2010036
Category: Medicine
Initiated: August 2010
Last Review: August 2018
  Chemical Peels

A chemical peel refers to a controlled removal of varying layers of the skin with use of a chemical agent. The most common use for chemical peeling is as a treatment of photoaged skin. However, chemical peeling has also been used as a treatment for other conditions including actinic keratoses, active acne and acne scarring.
Chemical peels involve a controlled partial-thickness removal of the epidermis and the outer dermis. When skin is regenerated, a 2-3 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 up to 15-20 years and may be permanent in some patients. Potential local complications include scarring, infection, hypopigmentation, hyperpigmentation, activation of herpes simplex and toxic shock syndrome (Habif, 2009).
Chemical peels are often categorized according to 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, duration of the application and the number of applications. Possible indications for each type of peel and common chemicals used, as described in 2005 by Cummings and colleagues (Cummings, 2005) and others, is as follows:
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, 10-20% trichloroacetic acid (TCA), Jessner’s 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 the 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 a total of 6 to 8 peels performed weekly or every other week.
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. In the past 50% TCA was a common chemical agent for medium-depth peels but its use has decreased due to a high rate of complications such as pigmentary changes and scarring. Currently, the most frequently used agent is a combination of 35% TCA with Jessner’s 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 a new, erythematous epithelium. Patients are advised to wait at least 3 months before resuming skin care services such as superficial chemical peels and repeat medium-depth chemical peels should not be performed for at least 1 year.
Deep chemical peels penetrate (another type of dermal peel) the midreticular dermis and are used for patients with severe photodamage, pre-malignant skin neoplasms, acne scars and dyschromias. The most common chemical agent used is Baker’s solution (which consists of 3mL of 88% phenol, 8 drops of septisol, 3 drops of croton oil and 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 medication that are could potentially precipitate an arrhythmia. Phenol can also have renal and hepatic toxicities.
The likelihood and potential severity of adverse effects increases as the strength of the chemicals and 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 patients willing to always wear makeup is advised. Moreover, chemical peels reduce melanin protection so patients must be use protective sunscreen for 9 to 12 months after a medium to deep facial peel.
Regulatory Status
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.
Requests for all chemical peels should be carefully evaluated to determine whether their rationale is primarily cosmetic.
There are a variety of CPT codes that describe chemical peels. CPT codes 15788 and 15789 describe epidermal peels, for the facial and nonfacial areas, respectively. CPT codes 15792 and 15793 describe the corresponding dermal peels. A distinct CPT code, 17360, specifically describes chemical exfoliation for acne. Chemical exfoliation may be considered part of the general dermatology evaluation and management services and, therefore, Plans may consider whether to accept separate billing for chemical exfoliation as a treatment of acne.

Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
Dermal chemical peels used to treat patients with numerous (>10) actinic keratoses or other premalignant skin lesions, such that treatment of the individual lesions becomes impractical, meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
Epidermal chemical peels used to treat patients with active acne that has failed a trial of topical and/or oral antibiotic acne therapy are considered medically necessary. In this setting, superficial chemical peels with 40% to 70% alpha hydroxy acids are used as a comedolytic therapy. (Alpha hydroxy acids can also be used in lower concentrations [8%] without the supervision of a physician.)
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
Epidermal chemical peels used to treat photoaged skin, wrinkles, or acne scarring or dermal peels used to treat end-stage acne scarring are considered cosmetic services.  Cosmetic Services are specific contract exclusions in most member benefit certificates of coverage.  For contracts without this exclusion, cosmetic services do not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes or are considered investigational.  Investigational services are specific contract exclusions in most member benefit certificates of coverage.

The policy was developed with a literature search of the MEDLINE database through July 2010. There were several review articles that discussed possible applications of chemical peels and two small published studies.
A key issue for the policy is the determination of whether the treatment is primarily cosmetic in nature. Regarding actinic keratoses, these are premalignant lesions, and the medical necessity for their destruction/removal is considered appropriate, although watchful waiting may also be an option. Review articles suggested that chemical peels might be appropriate when there are numerous lesions (i.e. 10 or more), making treatment of the individual lesions impractical and when the treatment constitutes a full-thickness necrosis of the epidermis which is considered curative (Morganroth, 1993) (Brodland, 1988). Photodynamic therapy is another option for the treatment of patients with multiple actinic keratoses.
Review articles also suggested that chemical peels may be appropriate for treatment of active acne when other treatments have failed (Van Scott, 1989).  While low concentrations of chemical agents can be administered by the patient at home, higher concentrations 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. 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.
Other applications of chemical peels, including treatment of photoaged skin, wrinkles and acne scarring were considered cosmetic.
Two small controlled studies evaluating chemical peels were identified. Both used randomized split-faced designs and compared the effects of two chemical peeling agents. The stronger study methodologically was published in 2008 by Kessler and colleagues (Kressler, 2008).  This single-center study evaluated chemical peels as adjuvant therapy in 20 patients who were at least 13 years old and had mild to moderately severe facial acne with a minimum of 10 papules and/or pustules. It compared treatment with an alpha-hydroxy acid (30% glycolic acid) and a beta-hydroxy acid peel (30% salicylic acid). Patients were treated every 2 weeks for a total of six weeks, and were followed for 2 months after the last treatment. Ten percent of the patients had completed a course of isoretinoin over a year before enrollment (used of isoretinoin within a year was an exclusion criterion). At the time of study enrollment, 75% of patients were using topical medication and 25% were on oral antibiotics; no changes in acne medication were allowed during the study period. The authors did not report the length of time that patients had been using other acne treatments. The primary outcome was clinical response according to a blinded evaluator, categorized as good (more than 50% improvement), fair (21%-50% improvement), poor (10-20% improvement), no change or worse. A total of 17 of the 20 patients were included in the analysis; 1 patient dropped out and 2 were lost to follow-up. At 1 month after the last treatment visit, acne lesions declined by 43% on the glycolic acid peel side and 47% on the salicylic acid peel side, a non-significant between-group difference. There was also no between-group difference in response at 2 months; the evaluator rated as having good or fair improvement 75% of the glycolic acid peel sides and 80% of the salicylic acid peel sides. Both chemical agents resulted in improvement compared to baseline. There were similar number of adverse events with each chemical agents; common adverse events were redness and scaling. A limitation of the study was that it did not include a control group of patients who did not receive chemical peeling so it is uncertain whether either type of peel was more effective than standard treatment.
The other study, published in 1999, was conducted in Korea by Kim and colleagues and reported on 26 patients with mild to moderate acne (Kim, 1999). The two treatments were 70% glycolic acid and Jessner’s solution (resorcinol, salicylic acid, and lactic acid in ethanol). Treatments were repeated 3 times every 2 weeks, for a total treatment period of 6 weeks. A blinded physician evaluated each face before each treatment and 2 weeks after the last treatment. The authors reported that 26 patients completed the study but did not state the number of patients who were initially included. Moreover, they reported the number of face sides judged to have improvement in acne (8 sides, 31%, improved with each chemical agent) but did not specify when this outcome was measured e.g. after the last treatment or at final follow-up. Also missing were any previous or concurrent acne treatments patients received. Finally, like the Kessler study, the study by Kim and colleagues lacked a control group that did not receive chemical peels.
No controlled studies evaluating chemical peels for treatment of actinic keratoses were identified. The search yielded one case series, a prospective study from Japan that included 46 patients, 32 with actinic keratoses and 14 with Bowen’s Disease (Kaminaka, 2009).  There was no minimum number of actinic keratoses required for inclusion; that is, the study did not specifically address treatment of multiple actinic keratoses. Patients received phenol peels with 100% pure phenol applied locally to the lesions once a month for a maximum of 8 months (less if a complete response was achieved) Biopsies were performed on all lesions before and at the end of therapy. Twenty-nine of the 32 (91%) patients with actinic keratoses achieved a complete response (defined as an undetectable lesion at least 1 month after the last phenol application). The average number of treatments for patients with actinic keratoses was 2.9. Ten of the 12 (83%) patients with Bowen’s Disease had a complete response and the average number of treatments in this group was 5.5. All patients were followed for at least a year after treatment; median follow-up was 2.8 years. By the 1-year follow-up, 2 of 46 patients (4.3%), 1 with actinic keratoses and 1 with Bowen’s Disease, had experienced recurrences. No systemic side effects were reported. The study was limited by lack of a control group, and a small sample size, especially in the sub-set of patients with Bowen’s Disease.
Technology Assessments, Guidelines and Position Statements
British Association of Dermatologists: In 2007, they published a guideline on the management of actinic keratoses (de Berker, 2007). Chemical peels were given a ‘C, III” rating, meaning that there is “poor evidence to support the use of the procedure” and the evidence consists of “opinions of respected authorities based on clinical experience, descriptive studies or reports of expert committees”.
American Academy of Dermatology: In 2007, they published a guideline on management of acne vulgaris which included the statement, “There is limited evidence regarding the benefit of physical modalities including glycolic acid peels and salicylic acid peels.” (Strauss, 2007)
There is a paucity of studies evaluating chemical peels. Review articles and clinical opinion supports the use of chemical peels for treating multiple actinic keratoses and as second-line treatment of active acne.. There are no studies that demonstrate the medical necessity for use of chemical peels in the treatment of photoaged skin or acne-related scarring.
2012 Update
This policy is updated with a literature search of the MEDLINE database through July 2012.  There was no new information identified that would prompt a change in the coverage statement.
In 2011, Levesque and colleagues in France published findings from a single-blind randomized split-face study that included 20 patients with active comedonal acne (Levesque, 2011). To be eligible, patients needed to have at least 5 noninflammatory acne lesions on each side of the face and to have fewer than 30 inflammatory acne lesions on the entire face. Participants were required to stop using other acne medications prior to starting the chemical peel treatment. The treatments being compared were a salicylic acid peel and a lipophilic hydroxic acid (LHA) derivative of salicylic acid; patients received one treatment to one side of their face (selected randomly) and the other treatment to the second side. Treatments occurred every other week for a total of 6 peels. At the end of the treatment period, the reduction in the proportion of noninflammatory lesions was 55.6% on the LHA side and 48.5% on the salicylic acid side; the difference between groups was not statistically significant, p=0.88. The number of lesions decreased significantly between baseline and the end of treatment in both groups, p<0.001. Both treatments were well-tolerated (as assessed by a global tolerance scale); there was no significant difference between treatments in erythema, p=0.10.
A single-blind split-face randomized trial in acne patients was published in 2010 by Ilknur and colleagues in Turkey (Ilknur, 2010). Treatments being compared in this study were glycolic acid peels and amino fruit peels. The study included 30 patients with non-inflamed lesions and superficial inflamed lesions, with acne grades 0.25 to 2 according to Leeds criteria. Patients received a series of 12 peels on the 2 halves of their face at 2-week intervals (total of 6 months). Twenty-four of 30 (80%) patients completed the study. The mean number of non-inflamed lesions on the glycolic acid side decreased from 49.1 (standard deviation [SD]: 40.6) at baseline to 18.3 (SD: 12.9) at 6 months. The mean number of non-inflamed lesions on the amino fruit acid side decreased from 45.6 (SD: 43.5) at baseline to 17.1 (SD: 14.2) at 6 months. The reduction in lesions was not significantly different between groups. Findings were similar for the other primary outcome, number of superficial inflamed lesions. At 6 months, the number of inflamed lesions was 6.9 (SD: 5.2) on the glycolic acid side and 7.0 (SD: 7.3) on the amino fruit acid side (p>0.05).
2013 Update
A literature search conducted using the MEDLINE database through August 2013. There was no new information identified that would prompt a change in the coverage statement.
One small prospective study was identified. In 2013, Bae and colleagues published a single-blind split-face study comparing chemical peels with salicylic acid and Jessner’s solution in 13 Korean patients with active acne who were otherwise healthy and had not undergone acne treatment for at least the previous 3 months (Bae, 2013). It is unclear whether the study was randomized. Patients received a total of 3 treatment sessions; sessions occurred at 2-week intervals. On the side treated with Jessner’s solution, inflammatory lesion count decreased from a mean of 14.5 at baseline to a mean of 8.8 after the third treatment. Comparable numbers for the salicylic acid side were a mean of 12.2 at baseline to a mean of 7.8 after the third treatment. For non-inflammatory lesions, mean count on the Jessner’s solution side was 18.6 at baseline and 14.3 after the third treatment. Mean counts on the salicylic acid side were 22.7 at baseline and 14.7 after the third treatment. Between-group statistics were not reported.
2014 Update
A literature search conducted through July 2014 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
Only 1 RCT was identified that included a placebo group; the others compared 2 chemical peel protocols to one another. The placebo-controlled trial was published in 2014 by Kaminaka et al in Japan (Kaminaka, 2014). It was double-blind and included 26 patients with moderate to severe facial acne. Patients with moderate acne had 6 to 20 inflammatory lesions and up to 20 noninflammatory lesions, and patients with severe acne had 21 to 50 inflammatory lesions. Failure of previous treatments was not an explicit inclusion criterion. Patients were required to undergo a washout period of 2 months before study participation where they could not use topical or oral antibiotics, retinoids or corticosteroids. Participants then received a chemical peel treatment on a randomly selected side of the face and a placebo peel on the other side. Both treatments used the same pH acid gel vehicle (pH 2.0) and the active treatment was a 40% glycolic acid peel. Treatments were given every 2 weeks for a total of 5 applications, and the follow-up visit occurred 2 weeks after the last session (ie, at 10-week follow-up). The overall therapeutic effect was judged by a blinded dermatologist as excellent or good for 23 (92%) of the chemical peel sides and 10 (40%) of the placebo sides; the difference between groups was statistically significant (p<0.01). Moreover, there were statistically significant reductions in inflammatory lesions and total lesion counts at each 2 week assessment and at the final 10-week assessment. No serious side effects or systematic adverse effects were reported.
In 2014, the first placebo-controlled randomized trial evaluating chemical peels for active acne was published and this trial found significantly better outcomes after treatment with a 40% glycolic acid peel compared with placebo treatment.
2015 Update
A literature search conducted using the MEDLINE database through July 2015 did not reveal any new information that would prompt a change in the coverage statement.   
2017 Update
A literature search conducted through July 2017 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
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 United States of 11% to 26% (Costa, 2015). These lesions are generally considered to be a precursor of squamous cell carcinoma (SCC) (Padilla, 2010). The risk of progression to invasive SCC is unclear, but estimates vary from 0.1% to 20% (Costa, 2015). For patients with multiple actinic keratoses, the risk of developing invasive SCC is estimated as being between 0.15% and 80%. Treatment options include watchful waiting, medication treatment, cryosurgery, surgical resection.
One nonrandomized split-face study was identified. This trial, by Lawrence and colleagues included 15 male patients with multiple facial actinic keratoses in similar numbers on both sides of the face (Lawrence, 1995). Patients were treated on the left side with a single application of Jessner solution and trichloroacetic acid 35% and on the right side with fluorouracil cream 5% twice daily for 3 weeks. The efficacy of both treatments was similar. The difference in the number of actinic keratoses on the left versus right side of the face was not statistically significant at 6 or 12 months (p>0.01). Both treatments were associated with nonserious adverse effects. On the chemical peel side of the face, patients developed erythema and mild desquamation lasting an average of 10 days in all but 1 patient, for whom the adverse effect lasted 3 months. On the fluorouracil cream side of the face, there was erythema, scaling, erosion, and crusting; these adverse effects persisted an additional 2 to 3 weeks beyond 3-week treatment period.
Dayal and colleagues in India published a parallel-group RCT comparing salicylic acid 30% peels to peels using Jessner solution in patients with mild-to-moderate facial acne (Dayal, 2016). Patients received 6 chemical peels using either solution; treatments were performed 2 weeks apart. At the end of the 12-week treatment period, the percent decrease in mean number of comedones was 53% in the salicylic acid group and 26% in the Jessner solution group (p=0.001). However, there was no significant difference in the decrease in mean papule counts (p=0.87) or mean pustule counts (p=0.57) at 12 weeks. The mean Michaelson Acne Severity Score, which is based on the number of comedones, papules, and pustules, was significantly better in the salicylic acid group at 12 weeks than in the Jessner solution group (p=0.002). Both treatments were generally well tolerated. Postpeel burning and stinging was more common with salicylic acid and postpeel erythema was more common with the Jessner solution.
A search of in July 2017 did not identify any ongoing or unpublished trials that would likely influence this review.
2018 Update
Annual policy review completed with a literature search using the MEDLINE database through July 2018. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
American Society for Dermatologic Surgery
The American Society for Dermatologic Surgery published recommendations in 2017 on the use of several skin treatments following a course of isotretinoin, a treatment for severe cystic acne (Waldman, 2017). Previously, a number of 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.

15788Chemical peel, facial; epidermal
15789Chemical peel, facial; dermal
15792Chemical peel, nonfacial; epidermal
15793Chemical peel, nonfacial; dermal
17360Chemical exfoliation for acne (eg, acne paste, acid)

References: Padilla RS, Sebastian S, Jiang Z, et al.(2010) 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. PMID 20231500

Abdel Meguid AM, Elaziz Ahmed Attallah DA, Omar H.(2015) Trichloroacetic acid versus salicylic acid in the treatment of acne vulgaris in dark-skinned patients. Dermatol Surg. Dec 2015;41(12):1398-1404. PMID 26551771

Bae BG, Park CO, Shin H et al.(2013) Salicylic acid peels versus Jessner's solution for acne vulgaris: a comparative study. Dermatol Surg 2013; 39(2):248-53.

Brodland DG, Roenigk RK.(1988) Trichloroacetic acid chemexfoliation (chemical peel) for extensive premalignant actinic damage of the face and scalp. Mayo Clin Proc 1988; 63(9):887-96.

Costa C, Scalvenzi M, Ayala F, et al.(2015) How to treat actinic keratosis? An update. J Dermatol Case Rep. Jun 30 2015;9(2):29-35. PMID 26236409

Cummings CW, Haughey BH, Thomas JR et al.(2005) Otolaryngology: Head and Neck Surgery, 4th edition. 2005: Mosby. Chapter 29.

Dayal S, Amrani A, Sahu P, et al.(2016) Jessner's solution vs. 30% salicylic acid peels: a comparative study of the efficacy and safety in mild-to-moderate acne vulgaris. J Cosmet Dermatol. Aug 25 2016. PMID 27557589

de Berker D, McGregor JM, Hughes BR;(2007) British Association of Dermatologists Therapy Guidelines and Audit Subcommittee. Guidelines for the management of actinic keratoses. Br J Dermatol 2007; 156(2):222-30.

Habif TP(2009) Clinical Dermatology 5th Edition. 2009. Mosby. Chapter 27.

Ilknur T, Demirtasoglu M, Bicak MU et al.(2010) Glycolic acid peels versus amino fruit acid peels for acne. J Cosmet Laser Ther 2010; 12(5):242-5.

Kaminaka C, Uede M, Matsunaka H et al.(2014) 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):314-22.

Kaminaka C, Yamamoto Y, Yonei N et al.(2009) 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 2009; 60(4):615-25.

Kessler E, Flanagan K, Chia C et al.(2008) Comparison of alpha- and beta-hydroxy acid chemical peels in the treatment of mild to moderately severe facial acne vulgaris. Dermatol Surg 2008; 34(1):45-51.

Kim SW, Moon SE, Kim JA et al.(1999) Glycolic acid versus Jessner’s solution: which is better for facial acne patients? A randomized prospective clinical trial of split-face model therapy. Dermatol Surg 1999; 25(4):270-3.

Lawrence N, Cox SE, Cockerell CJ, et al.(1995) 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. PMID 7857114

Levesque A, Hamzavi I, Seite S et al.(2011) Randomized trial comparing a chemical peel containing a lipophilic hydroxy acid derivative of salicylic acid with a salicylic acid peel in subjects with comedonal acne. J Cosmet Dermatol 2011; 10(3):174-8.

Morganroth GS, Leffell DJ.(1993) Nonexcisional treatment of benign and premalignant cutaneous lesions. Clin Plast Surg 1993; 20(1):91-104.

Purdy S, de Berker D.(2011) Acne vulgaris BMJ Clin Evid. Jan 05 2011;2011. PMID 21477388

Strauss JS, Krowchuk DP, Leyden JJ et al;(2007) American Academy of Dermatology/American Academy of Dermatology Association. Guidelines of care for acne vulgaris management. J Am Acad Dermatol 2007; 56(4):651-63.

Van Scott EJ, Yu RJ.(1989) Alpha hydroxy acids: Procedures for use in clinical practice. Cutis 1989; 43(3):222-8.

Waldman A, Bolotin D, Arndt KA, et al.(2017) 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. PMID 28498204

Zaenglein AL, Pathy AL, Schlosser BJ, et al.(2016) Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. May 2016;74(5):945-973 e933. PMID 26897386

Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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