Confocal Laser Endomicroscopy

Policy ID: M-78-008

Section: Diagnostic Medical

Effective Date: March 01, 2020

Revised Date: January 20, 2020

Last Reviewed: July 26, 2023

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 patients with inflammatory bowel disease or Barrett esophagus.

Criteria

CLE is considered experimental/investigational and therefore, non-covered. 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

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.

Section: Diagnostic Medical

Effective Date: March 01, 2020

Revised Date: January 22, 2020

Last Reviewed: January 02, 2020

Archived Date: March 17, 2021

Applies To: Commercial Only