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DESCRIPTIONConfocal 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 histology during colonoscopy and for targeting areas to undergo biopsy in patients with inflammatory bowel disease and Barrett’s esophagus.
Confocal laser endomicroscopy (CLE), also known as confocal fluorescent endomicroscopy and optical endomicroscopy, allows in vivo microscopic imaging of the mucosal epithelium during endoscopy. The process involves using light from a low-power laser to illuminate tissue and, subsequently, the same lens detects light reflected from the tissue through a pinhole. The term confocal refers to having both illumination and collection systems in the same focal plane. Light reflected and scattered at other geometric angles that is not reflected through the pinhole is excluded from detection, which dramatically increases the special resolution of CLE images.
To date, 2 types of CLE systems have been cleared by the U.S. Food and Drug Administration (FDA). One is an endoscope-based system in which a confocal probe is incorporated onto the tip of a conventional endoscope. The other is a probe-based system; the probe is placed through the biopsy channel of a conventional endoscope. The depth of view is up to 250 µm with the endoscopic system and about 120 µm with the probe-based system. A limited area can be examined; no more than 700 µm in the endoscopic-based system and less with the probe-based system. As pointed out in review articles, the limited viewing area emphasizes the need for careful conventional endoscopy to target the areas for evaluation. Both CLE systems are optimized using a contrast agent. The most widely used agent is intravenous fluorescein, which is FDA-approved for ophthalmologic imaging of blood vessels when used with a laser scanning ophthalmoscope.
Unlike techniques such as chromoendoscopy, which are primarily intended to improve the sensitivity of colonoscopy, CLE is unique in that it is designed to immediately characterize the cellular structure of lesions. CLE can thus potentially be used to make a diagnosis of polyp histology, particularly in association with screening or surveillance colonoscopy, which could allow for small hyperplastic lesions to be left in place rather than removed and sent for histological evaluation. This would reduce risks associated with biopsy and reduce the number of biopsies and histological evaluations.
Another key potential application of CLE technology is targeting areas for biopsy in patients with Barrett’s esophagus undergoing surveillance endoscopy. This is an alternative to the current standard approach recommended by the American Gastroenterological Association (AGA) which is that patients with BE who do not have dysplasia undergo endoscopic surveillance every 3 to 5 years. AGA further recommends that random 4-quadrant biopsies every 2 cm be taken with white-light endoscopy in patients without known dysplasia.
Other potential uses of CLE under investigation include better diagnosis and differentiation of conditions such as gastric metaplasia, lung cancer and bladder cancer.
As noted previously, limitations of CLE systems include a limited viewing area and depth of view. Another issue is standardization of systems for classifying lesions viewed with CLE devices. Although there is not currently an internationally accepted classification system for colorectal lesions, 2 systems have been developed that have been used in a number of studies conducted in different countries. These are the Mainz criteria for endoscopy-based CLE devices and the Miami classification system for probe-based CLE devices. Lesion classification systems are less developed for non-gastrointestinal lesions viewed by CLE devices e.g., those in the lung or bladder. Another potential issue is the learning curve for obtaining high-quality images and classifying lesions. Several recent studies, however, have found that the ability to acquire high-quality images and interpret them accurately can be learned relatively quickly; these studies were limited to colorectal applications of CLE.
The following two confocal laser endomicroscopy devices have been cleared for marketing by the FDA:
Related medical policies are –
POLICYUse of confocal laser endomicroscopy is considered investigational.
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY03/21/2013: Approved by Medical Policy Advisory Committee.
03/11/2014: Policy reviewed; no changes.
02/09/2015: Policy reviewed; description updated. Policy statement unchanged.
07/13/2015: Code Reference section updated for ICD-10.
12/18/2015: Policy reviewed. Policy statement unchanged. Investigative definition updated in Policy Guidelines.
SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.87
This may not be a comprehensive list of procedure codes applicable to this policy.
Esophagoscopy, rigid or flexible; with optical endomicroscopy
Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with optical endomicroscopy
Optical endomicroscopic image(s), interpretation and report, real-time or referred, each endoscopic session