mp-494 - mp-494 - Medical Policies
Chromoendoscopy as an Adjunct to Colonoscopy
Policy Number: MP-494
Latest Review Date: December 2020
Policy Grade: B
Chromoendoscopy is considered not medically necessary and investigational as an adjunct to diagnostic or surveillance colonoscopy.
Virtual chromoendoscopy is considered not medically necessary and investigational as an adjunct to diagnostic or surveillance colonoscopy.
DESCRIPTION OF PROCEDURE OR SERVICE:
Chromoendoscopy refers to the application of dyes or stains during endoscopy to enhance tissue differentiation or characterization. When used with colonoscopy, the intent is to increase the sensitivity of the procedure by facilitating the identification of mucosal abnormalities. There are two types of chromoendoscopy: one involves actual spraying of dyes or stains through the working channel of an endoscope; the other, known as virtual chromoendoscopy uses a computer algorithm to simulate different colors of light that results from dye or stain spraying.
Colonoscopy, a procedure during which colonic and rectal polyps can be identified and removed, is considered the criterion standard test for colorectal cancer screening and diagnosis of colorectal disease. However, colonoscopy is an imperfect test. A 2006 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. Most of the missed polyps 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 enhance the sensitivity of colonoscopy. Chromoendoscopy, also known as chromoscopy and chromocolonoscopy, refers to the application of topical stains or dyes during endoscopy to enhance tissue differentiation or characterization and facilitate identification of mucosal abnormalities. Chromoendoscopy may be particularly useful for detecting flat or depressed lesions. A 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 (pancolonic 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.
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). Reactive stains are primarily used to identify gastric abnormalities and are not used with colonoscopy.
Potential applications of chromoendoscopy as an adjunct to standard colonoscopy include:
- Diagnosis of colorectal neoplasia in symptomatic patients at increased risk of colorectal cancer due to a family history of colorectal cancer, a 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 review articles and technology assessments have indicated 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 (also called electronic 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 most recent literature review was updated through October 6, 2020.
Summary of Evidence
For individuals who have an average risk of colorectal cancer (CC) who receive chromoendoscopy, the evidence includes RCTs focused on this population. The relevant outcomes are overall survival (OS), disease-specific survival (DSS), test validity, and change in disease status. The single RCT performed in the U.S. did not find that high-definition chromoendoscopy identified more clinically meaningful lesions than high-definition white-light colonoscopy. The evidence is insufficient to determine the effects of technology on net health outcomes.
For individuals who have an increased risk of CC who receive chromoendoscopy, the evidence includes multiple RCTs, and systematic reviews. The relevant outcomes are OS, DSS, test validity, and change in disease status. A Cochrane systematic review of trials comparing chromoendoscopy with standard colonoscopy in high-risk patients (but excluding those with inflammatory bowel disease) found significantly higher rates of adenoma detection and rates of three or more adenomas with chromoendoscopy than with standard colonoscopy. The evidence for detecting larger polyps, defined as greater than 5 mm or greater than 10 mm, is less robust. While one study reported a significantly higher detection rate for polyps greater than 5 mm, no studies reported increased detection of polyps greater than 10 mm. A recent RCT and systematic review involving patients with Lynch syndrome also found equivocal results. Results from the RCT showed similar neoplasia detection rates with chromoendoscopy and conventional whitelight colonoscopy while the systematic review concluded that chromoendoscopy is associated with significantly improved detection of certain lesions; however, the odds of having any adenoma detected were not significantly different between the modalities. The evidence is insufficient to determine the effects of the technology on net health outcomes.
For individuals who have inflammatory bowel disease (IBD) who receive chromoendoscopy, the evidence includes prospective and retrospective studies and meta-analyses. The relevant outcomes are OS, DSS, test validity, and change in disease status. The meta-analysis found a statistically significant higher yield of chromoendoscopy over white-light colonoscopy for detecting dysplasia. This evidence established that chromoendoscopy improves polyp detection rates; however, it is unclear whether the additional polyps detected are clinically important and, therefore, whether improved polyp detection rates will translate into improved health outcomes. Moreover, there are concerns about comparison groups used in some of these trials. It is uncertain whether the control groups received optimal colonoscopy; therefore, the improved detection rates by chromoendoscopy might have been a function of suboptimal standard colonoscopy. The evidence is insufficient to determine the effects of the technology on net health outcomes.
For individuals who have an average risk of CC who receive virtual chromoendoscopy, the evidence includes several RCTs and systematic reviews. The relevant outcomes are OS, DSS, test validity, and change in disease status. The available RCTs have not found that virtual chromoendoscopy improves the detection of clinically important polyps compared with standard white-light colonoscopy. Moreover, there is a lack of studies on the impact of virtual chromoendoscopy on CC incidence or mortality rates compared with standard colonoscopy. The evidence is insufficient to determine the effects of technology on net health outcomes.
For individuals who have an increased risk of CC who receive virtual chromoendoscopy, the evidence includes RCTs. The relevant outcomes are OS, DSS, test validity, and change in disease status. The available RCTs have not found that virtual chromoendoscopy improves the detection of clinically important polyps compared with standard white-light colonoscopy. Moreover, there is a lack of studies on the impact of virtual chromoendoscopy on CC incidence or mortality rates compared with standard colonoscopy. The evidence is insufficient to determine the effects of the technology on net health outcomes.
For individuals who have inflammatory bowel disease who receive virtual chromoendoscopy, the evidence includes an RCT and nonrandomized comparative study. The relevant outcomes are OS, DSS, test validity, and change in disease status. The RCT found a significantly greater likelihood that virtual chromoendoscopy would correctly identify the extent of disease inflammation than standard colonoscopy but no significant difference in the likelihood of identifying disease activity. A retrospective cohort study found that targeted biopsy resulted in a higher rate of neoplasia detection regardless of endoscopy method used. There is a lack of studies on the impact of virtual chromoendoscopy on CC incidence or mortality rates compared with standard colonoscopy. The evidence is insufficient to determine the effects of the technology on net health outcomes.
PRACTICE GUIDELINES AND POSITION STATEMENTS
American Society for Gastrointestinal Endoscopy and the American Gastroenterological Association
In 2015, the American Society for Gastroenterology (ASGE) and the American Gastroenterological Association (AGA) published the SCENIC consensus statement on surveillance and management of dysplasia in patients with IBD. The statement was developed by an international multidisciplinary group representing a variety of stakeholders, and incorporated systematic reviews of the literature. Relevant recommendations are as follows (see Table 1).
Table 1. Recommendations on Surveillance and Management of Dysplasia in Patients With Inflammatory Bowel Disease
“When performing surveillance with white-light colonoscopy, high definition is recommended rather than standard definition.”
“When performing surveillance with standard-definition colonoscopy, chromoendoscopy is recommended rather than white-light colonoscopy.”
“When performing surveillance with high-definition colonoscopy, chromoendoscopy is suggested rather than white-light colonoscopy.”
LOA: level of agreement; QOE: quality of evidence; SOR: strength of recommendation.
Panelists did not reach consensus on the use of chromoendoscopy in random biopsies of patients with IBD undergoing surveillance.
Commentaries in two gastroenterology journals questioned whether the SCENIC guidelines would be accepted as the standard of care in IBD surveillance. Both commentaries noted that the guidelines considered the outcome of detection of dysplasia and not disease progression or survival. Moreover, the authors noted the lack of longitudinal data on clinical outcomes in patients with dysplastic lesions detected using chromoendoscopy.
American Society for Gastrointestinal Endoscopy (ASGE)
In 2015, the ASGE issued guidelines on endoscopy in the diagnosis and treatment of IBD, which makes the following recommendations about chromoendoscopy: “Chromoendoscopy with pancolonic dye spraying and targeted biopsies is sufficient for surveillance in IBD; consider 2 biopsies from each colon segment for histologic staging.”
In 2015, the ASGE also published a systematic review and meta-analysis assessing narrow-band imaging, i-SCAN, and Fujinon Intelligent Color Enhancement for predicting adenomatous polyp histology of small or diminutive colorectal polyps to determine whether they have met previously established criteria or thresholds to incorporate into clinical practice. The ASGE assessment confirmed that:
“…The thresholds have been met for narrow-band imaging with endoscopists who are experts in using these advanced imaging technologies and when assessments are made with high confidence. The ASGE Technology Committee endorsed the use of NBI for both the ‘diagnose-and-leave’ strategy for diminutive (≤5 mm) rectosigmoid hyperplastic polyps and the ‘resect-and-discard’ strategy for diminutive (≤5mm) adenomatous polyps.”
The report addressed the “trepidation” of patients, endoscopists, and pathologists with the “diagnose-and-leave” strategy, indicating there are challenges for implementation for the use of these strategies in clinical practice.
U.S. Multi-Society Task Force on Colorectal Cancer
In 2020, the Multi-Society Task Force issued guidelines on the endoscopic removal of colorectal lesions. Regarding lesion assessment and description, the Task Force suggested "proficiency in the use of electronic- (eg, NBI, i-SCAN, and Fuji Intelligent Chromoendoscopy, or blue light imaging) or dye (chromoendoscopy)-based image-enhanced endoscopy techniques to apply optical diagnosis classifications for colorectal lesion histology [conditional recommendation, moderate-quality evidence)." The Task Force also suggested "careful examination of the post-mucosectomy scar site using enhanced imaging, such as dye-based (chromoendoscopy) or electronic-based methods, as well as obtaining targeted biopsies of the site. Post-resection scar sites that show both normal macroscopic and microscopic (biopsy) findings have the highest predictive value for long-term eradication [conditional recommendation, moderate-quality evidence]."
The 2012 Multi-Society Task Force guidelines on colonoscopy surveillance after screening and polypectomy (consensus update) stated that chromoendoscopy and NBI might enable endoscopists to accurately determine if lesions are neoplastic and if there is a need to remove them and send specimens to pathology. The guidelines noted that these technologies currently do not have an impact on surveillance interval.
U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATIONS
The 2016 U.S. Preventive Services Task Force recommendations on screening for colorectal cancer do not mention chromoendoscopy.
Chromoendoscopy, Chromoscopy, Chromocolonoscopy. Virtual chromoendoscopy, FICE, i-scan, NBI
APPROVED BY GOVERNING BODIES:
In August 2014, the Fujifilm EPX-4440HD Digital Video Processor with FICE and Light Source was cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. FDA documents state that FICE can be used to supplement white-light endoscopy but is not intended to replace histopathologic sampling as a means of diagnosis.
In April 2013, the i-scan™ (Pentax), used for virtual chromoendoscopy, was cleared for marketing by the FDA through the 510(k) process. This is a digital image enhancement technology and is part of the Pentax EPK-i5010 Video Processor. This digital image enhancement technology is part of the Pentax EPK-i5010 Video Processor. The i-SCAN™ has several modes that digitally enhance images in real-time during endoscopy. The FDA documents stated that i-SCAN™ is intended as an adjunct following white-light endoscopy but not intended to replace histopathologic analysis.
No dye or stain product has been specifically approved by the FDA for use in chromoendoscopy.
Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.
ITS: Home Policy provisions apply.
FEP: Special benefit consideration may apply. Refer to member’s benefit plan. FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.
There is no specific coding for chromoendoscopy. The additional work of the chromoendoscopy would probably be reported with the unlisted CPT code 44799 (unlisted procedure, intestine) or 78299 (unlisted gastrointestinal procedure, diagnostic nuclear medicine).
- Abu Dayyeh BK, Thosani N, Konda V, et al. ASGE Technology Committee systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc. Mar 2015;81(3):502.e501-502.e516.
- American Society for Gastrointestinal Endoscopy (ASGE). ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease. Available online at: www.guideline.gov.
- Brown SR, Baraza W, Din S, et al. Chromoscopy versus conventional endoscopy for the detection of polyps in the colon and rectum. Cochrane Database Syst Rev. 2016;4:CD006439.
- Brown SR, Baraza W. Chromoscopy versus conventional endoscopy for the detection of polyps in the colon and rectum. Cochrane Database Syst Rev 2010; (10):CD006439.
- Cha JM, Lee JI, Joo KR et al. A prospective randomized study on computed virtual chromoendoscopy versus conventional colonoscopy for the detection of small colorectal adenomas. Dig Dis Sci 2010; 55(8):2357-64.
- Chung SJ, Kim D, Song JH et al. Comparison of detection and miss rates of narrow band imaging, flexible spectral imaging chromoendoscopy and white light at screening colonoscopy: a randomized controlled back-to-back study. Gut 2013.
- Chung SJ, Kim D, Song JH et al. Efficacy of computed virtual chromoendoscopy on colorectal cancer screening: a prospective, randomized back-to-back trial of Fuji Intelligent Color Enhancement versus conventional colonoscopy to compare adenoma miss rates. Gastrointest Endosc 2010; 72(1):136-42.
- Desai M, Viswanathan L, Gupta N, et al. Impact of Electronic Chromoendoscopy on Adenoma Miss Rates During Colonoscopy: A Systematic Review and Meta-analysis. Dis Colon Rectum. Sep 2019; 62(9): 1124-1134.
- Farraye FA, Odze RD, Eaden JAGAIMPPoD et al. AGA Medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology 2010; 138(2):738-45.
- Feuerstein JD, Rakowsky S, Sattler L, et al. Meta-analysis of dye-based chromoendoscopy compared with standard- and high-definition white-light endoscopy in patients with inflammatory bowel disease at increased risk of colon cancer. Gastrointest Endosc. Aug 2019; 90(2): 186-195.e1.
- Food and Drug Administration (FDA). 510(k) Summary: Pentax EPK-i5010 Video Processor. 2013. Available online at: www.accessdata.fda.gov/cdrh_docs/pdf12/K122470.pdf.
- Food and Drug Administration (FDA). 510(k) Summary: Pentax EPK-i5010 Video Processor. 2013; http://www.accessdata.fda.gov/cdrh_docs/pdf12/K122470.pdf. Accessed September 25, 2020.
- Food and Drug Administration (FDA). Medical and Radiation Emitting Device Recalls. Class 2 Recall, EPX-4400 and EPX-4400HDVideo Processor. Available online at //www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfRes/resCollection_2.cfm?ID=96961&CREATE_DT=2011-02-09.
- Freire P, Figueiredo P, Cardoso R, et al. Surveillance in ulcerative colitis: is chromoendoscopy-guided endomicroscopy always better than conventual colonoscopy? A randomized trial. Inflamm Bowel Dis. Nov 2014; 20(11): 2038-2045.
- Gasia MF, Ghosh S, Panaccione R, et al. Targeted Biopsies Identify Larger Proportions of Patients With Colonic Neoplasia Undergoing High-Definition Colonoscopy, Dye Chromoendoscopy, or Electronic Virtual Chromoendoscopy. Clin Gastroenterol Hepatol. May 2016;14(5):704-712 e704.
- Haanstra JF, Dekker E, Cats A, et al. Effect of chromoendoscopy in the proximal colon on colorectal neoplasia detection in Lynch syndrome: a multicenter randomized controlled trial. Gastrointest Endosc. Oct 2019; 90(4): 624-632.
- Har-Noy O, Yung DE, Koulaouzidis A, et al. Chromoendoscopy or white light endoscopy for neoplasia detection in Lynch syndrome, a meta-analysis. Dig Liver Dis. Nov 2019; 51(11): 1515-1521.
- Higgins PD. Miles to Go on the SCENIC Route: Should chromoendoscopy become the standard of care in IBD surveillance? Am J Gastroenterol. Jul 2015;110(7):1035-1037.
- Hurlstone DP, Cross SS, Slater R et al. Detecting diminutive colorectal lesions at colonoscopy: a randomized controlled trial of pan-colonic versus targeted chromoscopy. Gut 2004; 53(3):376-80.
- Kahi CJ, Anderson JC, Waxman I et al. High-definition chromocolonoscopy vs. high-definition white light colonoscopy for average-risk colorectal cancer screening. Am J Gastroenterol 2010; 105(6):1301-7.
- Kaltenbach T, Anderson JC, Burke CA, et al. Endoscopic Removal of Colorectal Lesions-Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. Mar 2020; 158(4): 1095-1129.
- Karolinska University Hospital. Chromoendoscopy for dysplasia detection in chronic inflammatory bowel disease (NCT01505842). Available online at: www.clinicaltrials.gov.
- Kiesslich R, Goetz M, Lammersdorf K et al. Chromoscopy-guided endomicroscopy increases the diagnostic yield of intraepithelial neoplasia in ulcerative colitis. Gastroenterology 2007; 132(3):874-82.
- Kiriyama S, Matsuda T, Nakajima T et al. Detectability of colon polyp using computed virtual chromoendoscopy with flexible spectral imaging color enhancement. Diagn Ther Endosc 2012; 2012:596-303.
- Laine L, Kaltenbach T, Barkun A, et al. SCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease. Gastroenterology. Mar 2015;148(3):639-651 e628.
- Le Rhun M, Coron E, Parlier D et al. High resolution colonoscopy with chromoscopy versus standard colonoscopy for the detection of colonic neoplasia: a randomized study. Clin Gastroenterol Hepatol 2006; 4(3):349-54.
- Lieberman DA, Rex DK, Winawer SJ et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012; 143(3):844-57.
- Marion JF, Sands BE. The SCENIC consensus statement on surveillance and management of dysplasia in inflammatory bowel disease: praise and words of caution. Gastroenterology. Mar 2015;148(3):462-467.
- Marion JF, Waye JD, Israel Y, et al. Chromoendoscopy Is More Effective Than Standard Colonoscopy in Detecting Dysplasia During Long-term Surveillance of Patients With Colitis. Clin Gastroenterol Hepatol. May 2016;14(5):713-719.
- Marion JF, Waye JD, Present DH et al. Chromoendoscopy-targeted biopsies are superior to standard colonoscopic surveillance for detecting dysplasia in inflammatory bowel disease patients: a prospective endoscopic trial. Am J Gastroenterol 2008; 103(9):2342-9.
- Mooiweer E, van der Meulen-de Jong AE, Ponsioen CY, et al. Chromoendoscopy for surveillance in inflammatory bowel disease does not increase neoplasia detection compared with conventional colonoscopy with random biopsies: results from a large retrospective study. Am J Gastroenterol. Jul 2015;110(7):1014-1021.
- Neumann H, Vieth M, Gunther C et al. Virtual chromoendoscopy for prediction of severity and disease extent in patients with inflammatory bowel disease: a randomized controlled study. Inflamm Bowel Dis 2013; 19(9):1935-42.
- Omata F, Ohde S, Deshpande GA, et al. Image-enhanced, chromo, and cap-assisted colonoscopy for improving adenoma/neoplasia detection rate: a systematic review and meta-analysis. Scand J Gastroenterol. Feb 2014; 49 (2): 222-237.
- Pohl J, Lotterer E, Balzer C et al. Computed virtual chromoendoscopy versus standard colonoscopy with targeted indigocarmine chromoscopy: a randomized multicentre trial. Gut 2009; 58(1):73-8.
- Pohl J, Schneider A, Vogell H et al. Pancolonic chromoendoscopy with indigo carmine versus standard colonoscopy for detection of neoplastic lesions: a randomized two-centre trial. Gut 2011; 60(4):485-90.
- Rex DK, Kahi CJ, Levin B et al. Guidelines for colonoscopy surveillance after cancer resection: a consensus update by the American Cancer Society and US Multi-Society Task Force on Colorectal Cancer. CA Cancer J Clin 2006; 56(3):160-7; quiz 85-6.
- Shergill AK, Lightdale JR, Bruining DH, et al. The role of endoscopy in inflammatory bowel disease. Gastrointest Endosc. May 2015;81(5):1101-1121 e1101-1113.
- Sponsored by Universitaire Ziekenhuizen Leuven (Belgium). Comparison between chromoendoscopy and virtual chromoendoscopy (NBI, I-scan, FICE) for detection of neoplasia in long standing ulcerative colitis (NCT01882205). Available online at: clinicaltrials.gov.
- Stoffel EM, Turgeon DK, Stockwell DH et al. Chromoendoscopy detects more adenomas than colonoscopy using intensive inspection without dye spraying. Cancer Prev Res 2008; 1(6):507-13.
- Subramanian V, Mannath J, Ragunath K et al. Meta-analysis: the diagnostic yield of chromoendoscopy for detecting dysplasia in patients with colonic inflammatory bowel disease. Aliment Pharmacol Ther 2011; 33(3):304-12.
- USPSTF, Bibbins-Domingo K, Grossman DC, et al. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. Jun 21 2016;315(23):2564-2575.
- Van Rijn JC, Reitsma JB, Stoker J et al. Polyp miss rate determined by tandem colonoscopy: a systematic review. Am J Gastroenterol 2006; 101(2):343-50.
- Winawer SJ, Zauber AG, Fletcher RH et al. Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society. CA Cancer J Clin 2006; 56(3):143-59; quiz 84-5.
- Wu L, Li P, Wu J et al. The diagnostic accuracy of chromoendoscopy for dysplasia in ulcerative colitis: meta-analysis of six randomized controlled trials. Colorectal Dis 2012; 14(4):416-20.
- Zhao S, Wang S, Pan P, et al. Magnitude, Risk Factors, and Factors Associated With Adenoma Miss Rate of Tandem Colonoscopy: A Systematic Review and Meta-analysis. Gastroenterology. May 2019; 156(6): 1661-1674.e11.
Medical Policy Group, March, 2012 (4)
Medical Policy Administration Committee, March, 2012
Available for comment April 13 through May 28, 2012
Medical Policy Panel, March 2013
Medical Policy Group, April 2013 (3): 2013 Updates to Key Points and References; no change in policy statement
Medical Policy Panel, March 2014
Medical Policy Group, March 2014 (3): 2014 Updates to Key Points, Governing Bodies, & References; no change in policy statement
Medical Policy Panel, March 2015
Medical Policy Group, March 2015 (4): Updates to Key Points, Coding, and References. No change to policy statement.
Medical Policy Panel, November 2015
Medical Policy Group, November 2015 (4): Updates to Key Points and References; no change to policy statement.
Medical Policy Panel, November 2016
Medical Policy Group, January 2017 (4): Updates to Description, Key Points and References; no change to policy statement.
Medical Policy Panel, November 2017
Medical Policy Group, December 2017 (4): Updates to Key Points and References, no change to policy statement.
Medical Policy Panel, December 2018
Medical Policy Group, December 2018 (4): Updates to Key Points. No change to policy statement.
Medical Policy Panel, November 2019
Medical Policy Group, November 2019 (5): Updates to Description, Key Points, Approved by Governing Bodies, and Practice Guidelines and Position Statements. No change to Policy Statement.
Medical Policy Panel, November 2020
Medical Policy Group, December 2020 (5): Updates to Description, Key Points, Practice Guidelines and Position Statements, and References. No change to Policy Statement.
This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.
The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.
As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.
The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:
1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.
Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:
1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.