Medical Policy
Effective Date:03/01/2013 Title:Optical Endomicroscopy
Revision Date:04/01/2016 Document:BI392:00
CPT Code(s):43206, 43252, 0397T
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

QualChoice considers optical Endomicroscopy, confocal laser Endomicroscopy, Fuji Intelligent Chromo Endoscopy, and other similar techniques to be experimental and investigational, and these techniques are not covered.
Medical Statement

Optical Endomicroscopy is a technique that was developed for visually recognizing dysplasia and early cancer in the gastrointestinal tract.  In this technique, various methods are used to examine the lining of the esophagus or stomach to identify abnormalities that might warrant biopsy.  While theoretically promising, these techniques require additional study to determine their actual effect on important outcomes.  These techniques have been suggested primarily for surveillance in patients with Barrett’s esophagus, but also for diagnostic purposes in gastroscopy.

Codes Used in This Policy:

43206             Esophageal optical Endomicroscopy

43252             Upper GI optical Endomicroscopy

0397T             ERCP with optical Endomicroscopy
Limits
Intentially left empty
Reference

1.    Goetz M, Kiesslich R. Advanced imaging of the gastrointestinal tract: Research vs. clinical tools? Curr Opin Gastroenterol. 2009;25(5):412-421.

2.    Wallace MB, Crook JE, Saunders M, et al. Multicenter, randomized, controlled trial of confocal laser Endomicroscopy assessment of residual metaplasia after mucosal ablation or resection of GI neoplasia in Barrett`s esophagus. Gastrointest Endosc. 2012 Jun 28. [Epub ahead of print]

3.    Bertani H, Pigò F, Dabizzi E, et al. Advances in endoscopic visualization of Barrett`s esophagus: The role of confocal laser Endomicroscopy. Gastroenterol Res Pract. 2012;2012:493961.

4.    Bisschops R.  Confocal laser Endomicroscopy: finally ready to change clinical practice?.  Gastro Endo. 2011:7(4): 781-3.

5.    Falk G.  Probe-based confocal Endomicroscopy in Barrett’s esophagus: the real deal or another tease?  Gastro Endo. 2011:7(3) 473-6.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.