Confocal Laser Endomicroscopy

Policy ID: M-78-009

Section: Diagnostic Medical

Effective Date: March 01, 2020

Revised Date: January 20, 2022

Revision Effective Date: September 01, 2025

Last Reviewed: June 10, 2025

Applies To: Commercial and Medicaid Expansion

Description

Confocal laser endomicroscopy (CLE), also known as confocal fluorescent endomicroscopy and optical endomicroscopy, allows in vivo microscopic imaging of cells during endoscopy. CLE is proposed for a variety of purposes, especially as a real-time alternative to biopsy/polypectomy and histopathologic analysis during colonoscopy and for targeting areas to undergo biopsy in individuals with inflammatory bowel disease or Barrett esophagus.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

CLE is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

Procedure Codes

0397T

43206

43252

88375

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 New Policy

Internal Medical Policy Committee 3-17-2021 Annual Review-no changes

Internal Medical Policy Committee 3-23-2022 Annual Review, no changes in criteria

Internal Medical Policy Committee 3-23-2023 Annual Review, no changes in criteria

Internal Medical Policy Committee 7-26-2023 Annual Review, no changes in criteria

Internal Medical Policy Committee 7-16-2024 Annual Review, no changes in criteria

Added Policy Application

Internal Medical Policy Committee 6-10-2025 Annual Review, no changes in criteria

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: M-78-008

Section: Diagnostic Medical

Effective Date: March 01, 2020

Revised Date: January 20, 2020

Revision Effective Date: September 02, 2024

Last Reviewed: July 16, 2024

Archived Date: August 31, 2025

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Policy Application

Procedure Codes

0397T

43206

43252

88375

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 New Policy

Internal Medical Policy Committee 3-17-2021 Annual Review-no changes

Internal Medical Policy Committee 3-23-2022 Annual Review, no changes in criteria

Internal Medical Policy Committee 3-23-2023 Annual Review, no changes in criteria

Internal Medical Policy Committee 7-26-2023 Annual Review, no changes in criteria

Internal Medical Policy Committee 7-16-2024 Annual Review, no changes in criteria

Added Policy Application

Links

References (PDF)

Disclaimer

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