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Colonoscopy, a procedure during which colonic and recal polyps can be identified and removed, is considered the “gold standard” test for colorectal cancer screening and diagnosis of colorectal disease. However, colonoscopy is an imperfect test. A recent systematic review pooled findings from tandem (i.e. back-to-back) colonoscopy studies and found that 22% of polyps were missed on the first colonoscopy. (1) Most of the missed polyps, though, were small and, thus, lower-risk of becoming cancerous. The pooled miss rate by polyp size was 2% for polyps 10mm and larger, 13% for polyps 5-10mm and 26% for polyps 1-5mm.

Several adjunct endoscopic techniques, including chromoendoscopy, could potentially enhance the sensitivity of colonoscopy. Chromoendoscopy, also known as chromoscopy and chromocolonoscopy, refers to the application of topical stains or dyes during endoscopy in order to enhance and facilitate the identification of mucosal abnormalities. Chromoendoscopy may be particularly useful for detecting flat or depressed lesions. Standard colonoscopy uses white light to view the colon. In chromoendoscopy, stains are applied resulting in color highlighting of areas of surface morphology of epithelial tissue. The dyes or stains are applied via a spray catheter that is inserted down the working channel of the endoscope. Chromoendoscopy can be used in the whole colon (pan-colonic chromoendoscopy) on an untargeted basis or can be directed to a specific lesion or lesions (targeted chromoendoscopy). Chromoendoscopy differs from endoscopic tattooing in that the former uses transient stains whereas tattooing involves the use of a long-lasting pigment for future localization of lesions.

Stains and dyes used in chromoendoscopy can be placed in the following categories:

• Absorptive: These stains are preferentially absorbed by certain types of epithelial cells.
• Contrast: These stains seep through mucosal crevices and highlight surface topography.
• Reactive: These stains undergo chemical reactions when in contact with specific cellular constituents which results in a color change.

Reactive stains are primarily used to identify gastric abnormalities and are not used with colonoscopy.

Indigo carmine, a contrast stain, is the most commonly used stain with colonoscopy to enhance the detection of colorectal neoplasms. Several absorptive stains are also used with colonoscopy. Methylene blue, which stains the normal absorptive epithelium of the small intestine and colon, has been used to detect colonic neoplasia and to aid in the detection of intraepithelial neoplasia in individuals with chronic ulcerative colitis. In addition, crystal violet (also known as gentian violet), stains cell nuclei and has been applied in the colon to enhance visualization of pit patterns (i.e. superficial mucosal detail).

Potential applications of chromoendoscopy as an alternative to standard colonoscopy include:

• Diagnosis of colorectal neoplasia in symptomatic patients at increased risk of colorectal cancer due to family history of colorectal cancer, personal history of adenomas, etc.
• Identification of mucosal abnormalities for targeted biopsy as an alternative to multiple random biopsies in patients with inflammatory bowel disease (IBD)
• Screening the general population for colorectal cancer

The equipment used in regular chromoendoscopy is widely available. Several authors of review articles and technology assessments have stated that, although the techniques are simple, procedures, e.g. concentration of dye and amount of dye sprayed, is variable and classification of mucosal staining patterns for identifying specific conditions is not standardized.

Virtual chromoendoscopy involves imaging enhancements with endoscopy systems that could potentially be an alternative to dye spraying. One system is the Fujinon Intelligent Color Enhancement (FICE) feature (Fujinon, Inc.). This technology uses post-processing computer algorithms to modify the light reflected from the mucosa from conventional white light to various other wavelengths.

The Fujinon endoscope series EPX-4400 and EPX-4400HD (Fujinon, Inc.) have been cleared for marketing by the Food and Drug Administration (FDA) through the 510(k) process. The FDA determined that this device was substantially equivalent to existing devices for use in endoscopic observation, diagnosis, treatment and image recording. The Fujinon EPX-4400 and 4400HD systems include Fuji Intelligent Color Enhancement (FICE). This feature is intended to enhance the appearance of images and is used for virtual chromoendoscopy. On February 7, 2011, the FDA sent an Urgent Medical Device Corrective Action letter advising users that the FICE feature should no longer be used since this feature was not reviewed under the premarket notification/510k process. The letter further stated that a Fujinon Field Service Engineer would physically disable the FICE feature on all processors.

No dye or stain product has been specifically approved by the FDA for use in chromoendoscopy.

Virtual chromoendoscopy is considered investigational as an adjunct to diagnostic or surveillance colonoscopy.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

05/07/2013: Policy reviewed; no changes.

Non-Covered Codes

This is not an all-inclusive list of non-covered procedure codes.

All codes billed for this procedure are considered investigational and not eligible for coverage. 

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