Aetna Dysphagia Therapy Coverage Update

Coverage Summary

This Aetna Clinical Policy Bulletin (Number 0625, CURRENT) defines coverage for dysphagia therapies. Interventions Aetna considers medically necessary when criteria are met include: speech therapy for members meeting specified speech-therapy eligibility criteria, esophageal dilation for symptomatic esophageal obstruction, non-biodegradable, non-drug-eluting stent placement for refractory malignant esophageal strictures, and per-oral endoscopic myotomy (POEM) for type III (spastic) achalasia. Aetna considers a list of interventions experimental and investigational (not covered), including acupuncture, biodegradable stents, drug-eluting stents, electrical stimulation modalities, intensive dysphagia rehabilitation programs (e.g., Swallow STRONG) and multiple neuromodulation techniques.

Policy Number0625

SubjectDysphagia Therapy

StatusCURRENT

Effective Date06/28/2002

Last Review09/12/2023

Next Review07/11/2024

Medical-Necessity Criteria

Medical Necessity

Aetna considers the following interventions medically necessary for treatment of dysphagia when criteria are met:

ALL of the following

Speech therapy eligibility (ANY of)
- Member exhibits weight loss or malnutrition because he/she has dysphagia and is unable to obtain adequate nutrition orally
- Member has a history of, or is at high-risk for, recurrent aspirations or choking
- Member is unable to swallow and has a nasogastric or gastrotomy tube for nutrition
Esophageal dilation for the treatment of symptomatic obstruction of the esophagus

Experimental, Investigational, and Not Covered Interventions

Experimental and Investigational (Not Covered)

Aetna considers the following interventions experimental and investigational for treatment of dysphagia because effectiveness has not been established:

ANY of the following

Acupuncture
Biodegradable stent
Drug-eluting stents for esophageal strictures (malignant or benign)
Dysphagia therapy for all other indications other than the ones listed in Section I

Coding

Therapy for the management of dysphagia (other than esophageal dilation or stent placement) - CPT codes covered if selection criteria are metCPTCovered

43497	Lower esophageal myotomy, transoral (ie, peroral endoscopic myotomy [POEM])
92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual [not covered for intensive dysphagia rehabilitation program]
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals [not covered for intensive dysphagia rehabilitation program]
92526	Treatment of swallowing dysfunction and/or oral function for feeding
92610	Evaluation of oral and pharyngeal swallowing function
92611	Motion fluoroscopic evaluation of swallowing function by cine or video recording
92612	Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording
92613	Physician interpretation and report only

CPT codes not covered for indications listed in the CPB (procedures related to excluded therapies)CPTNot Covered

43229	Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) [not covered for ERBE electrocautery]
90867	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management
90868	Subsequent delivery and management, per session
90869	Subsequent motor threshold re-determination with delivery and management
97014	Application of a modality to one or more areas; electrical stimulation (unattended)
97032	Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes
97810-97814	Acupuncture

HCPCS codes covered if selection criteria are metHCPCSCovered

G0153	Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes
S9128	Speech therapy, in the home, per diem

HCPCS codes not covered for indications listed in the CPB (electrical/neuromuscular stimulators and drug-eluting stents)HCPCSNot Covered

E0720	Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation
E0730	Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation
E0745	Neuromuscular stimulator, electronic shock unit
G0283	Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
C1874	Stent, coated/covered, with delivery system [drug-eluted stent]
C1875	Stent, coated/covered, without delivery system [drug-eluted stent]

Other HCPCS related to stents (covered for non-biodegradable, non-drug eluting stents)HCPCSCovered

C1876	Stent, noncoated/noncovered, with delivery system
C1877	Stent, noncoated/noncovered, without delivery system
43212	Esophagoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)
43266	Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)

ICD-10 codes covered if selection criteria are met (dysphagia, achalasia, cerebrovascular sequelae, esophageal obstruction, malignant neoplasm)ICD-10Covered

I69.091 I69.191 I69.291 I69.391 I69.891 I69.991	Cerebrovascular disease, dysphagia, sequelae (listed as covered for therapy management codes but also appears as not covered in other sections — see exclusions)
K22.0	Achalasia of cardia [Type III achalasia]
R13.10 - R13.19	Dysphagia
K22.2	Esophageal obstruction
Q39.0 - Q39.4 Q39.8	Congenital malformations of esophagus
C15.3 - C15.9	Malignant neoplasm of esophagus

ICD-10 codes not covered for indications listed in the CPBICD-10Not Covered

I69.091 I69.191 I69.291 I69.391 I69.891 I69.991	Sequelae of cerebrovascular disease, dysphagia (listed as not covered for esophageal dilation and stent placement indications)
R13.10 - R13.19	Dysphagia (not covered for esophageal dilation and stent placement indications)

Esophageal dilation CPT codes covered if selection criteria are metCPTCovered

43196	Esophagoscopy, rigid, transoral; with insertion of guide wire followed by dilation over guide wire
43213	Esophagoscopy, flexible, transoral; with dilation of esophagus, by balloon or dilator, retrograde (includes fluoroscopic guidance, when performed)
43214	With dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)
43220	Esophagoscopy, rigid or flexible; with balloon dilation (less than 30 mm diameter)
43226	With insertion of guide wire followed by dilation over guide wire
43233	Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)
43249	Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus (less than 30 mm diameter)
43253	Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided transmural injection of diagnostic or therapeutic substance(s) or fiducial marker(s)
43270	Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)
43450	Dilation of esophagus, by unguided sound or bougie, single or multiple passes

1–10 of 11

1/2

Provider Actions and Documentation Requirements

Documentation Required

Verify speech therapy medical necessity criteria

Document that the member meets at least one of the specific speech therapy medical necessity criteria to justify coverage: weight loss or malnutrition due to dysphagia; history of, or high-risk for, recurrent aspiration or choking; or inability to swallow with a nasogastric or gastrostomy tube. Affected codes: 92507, 92508, 92526, 92610, 92611, 92612, 92613, G0153, S9128.

Weight loss or malnutrition because of dysphagia
History of, or high-risk for, recurrent aspiration or choking
Unable to swallow and receiving nutrition via nasogastric or gastrostomy tube

Documentation Required

Esophageal dilation indication documentation

Document symptomatic obstruction of the esophagus as the indication for esophageal dilation. Empiric dilation for non-obstructive esophageal dysphagia is not supported by the evidence. Affected esophageal dilation CPT codes include: 43196, 43213, 43214, 43220, 43226, 43233, 43249, 43253, 43270, 43450, 43453.

Background and Evidence Summary

Background summary: Dysphagia is difficulty or inability to swallow that can arise from dysfunction at any part of the swallowing process and from multiple causes, including neurologic diseases (stroke, traumatic brain injury, Parkinson's disease, cerebral palsy), structural or inflammatory esophageal disorders, congenital anomalies, head/neck/esophageal cancers, and treatment-related injury. Diagnostic evaluation commonly involves clinicians and speech-language pathologists using tests such as fiber optic laryngoscopy, videofluoroscopy, and ultrasound to assess swallowing physiology. Speech-language pathologists provide assessment and rehabilitative interventions, including oral-motor therapy and behavioral swallowing therapies. The policy reviews evidence and roles of specific interventions for dysphagia management: non-biodegradable self-expanding metal stents for palliation of malignant strictures (with considerations of stent diameter and complication profiles), biodegradable stents (limited and mixed results), guidance that esophageal dilation is indicated for symptomatic obstruction but not supported for non-obstructive dysphagia, botulinum toxin injection for select upper esophageal sphincter dysfunction (pilot data), and electrical stimulation approaches (including NMES, PES, rTMS, tDCS, and peripheral magnetic stimulation) with mixed-quality evidence and need for further research.

Citation	Key Finding
Verschuur et al (2007)	Large-diameter stents reduce recurrent dysphagia but may increase complications in some stent types
Conio et al (2007)	Polyflex vs Ultraflex: similar palliation but higher complications with Polyflex
Lavu et al (2004)	RCT found no support for empiric dilation in non-obstructive esophageal dysphagia
Long & Wu (2012) meta-analysis	Acupuncture RCTs suggest benefit post-stroke but poor study quality limits recommendations
Jiang et al (2022) meta-analysis	Acupuncture +/- rehabilitation may improve post-stroke dysphagia; evidence quality moderate to low
NMES + traditional therapy (Frost et al)	Small series: 9 subjects improved on FOIS; minor AEs in 1.3% electrode placements
Park et al (2018)	PD in Parkinson's: increased hyoid movement and reduced aspiration; no change in VFDS oral/pharyngeal phases
Von Renteln et al (2013) POEM cohort	70 patients: 97% remission at 3 months; 89% at 6 months; 82% at 12 months
Verlaan et al (2013) POEM (n=10)	Significant reductions in Eckardt score and LES pressure; reflux esophagitis in 6/10
Werner et al (2019) randomized trial	221 patients: POEM non-inferior to LHM+Dor at 2 yrs (83.0% vs 81.7%); higher reflux after POEM (44% vs29% at 24 months)
Schlottmann et al (2018) meta-review	POEM predicted dysphagia improvement ~93.5% vs LHM 91.0% at 12 months; higher GERD with POEM
Awaiz et al (2017) meta-analysis	Comparable overall complication and postoperative GERD rates between POEM and LHM in pooled trials but limited long-term data
Crespin et al (2017) systematic review	19 studies, 1,299 POEM procedures; significant Eckardt and LES improvements; median follow-up 13 months
Nabi et al (2017) cohort (n=408)	Clinical success 94% at 1yr; GERD documented in 28.3%; erosive esophagitis 18.5%
Repici et al (2018) systematic review	Higher pooled rates of post-procedural GER symptoms, abnormal acid exposure and esophagitis after POEM vs LHM
Facciorusso (2021) network meta-analysis	Low-quality evidence supports POEM and LHM over PD for 1-year success; POEM may have higher severe esophagitis incidence
Tan et al (2021) rescue POEM pooled rates	Rescue POEM technical success 98.0%; clinical success 90.8%; AE rate 10.3%
PES and PES reviews (Restivo & Hamdy, 2018)	Promising for stroke and MS neurogenic dysphagia; mixed results in large trials; small RCT meta-analysis suggested short-term effect
PAS (Michou 2012)	Short-term bilateral cortical excitability increases and improved swallowing metrics in chronic stroke dysphagia
rTMS trials and reviews (Khedr 2010; Pisegna 2016; Xie 2022)	RCTs and meta-analyses show moderate pooled effects on post-stroke dysphagia; variable evidence quality
Electrocautery incision vs Savary bougienage (Hordijk 2009)	No significant difference in dilations or success at 6 months; both safe
Biodegradable stent series (Griffiths 2012; Krokidis 2013)	Short-term dysphagia relief but high re-intervention/dysfunction rates; unclear long-term benefit
Cochrane review palliative interventions (Dai 2014)	SEMS safer and more effective than plastic tubes; brachytherapy may provide survival/quality benefit; combinations may reduce re-interventions
Swallow STRONG (Rogus-Pulia 2016)	n=56: increased lingual pressures, SWAL-QOL improvements, higher FOIS; decreased hospital admissions (p=0.009)
Botulinum toxin pilot (Terre 2008)	Single BTX-A injection in UES improved UES relaxation and pharyngeal contraction; 6 patients eating exclusively by mouth at 3 months
NMES systematic reviews (Carnaby-Mann 2007; Miller 2022)	Mixed/limited evidence; small significant effects in early meta-analysis; recent reviews report benefit as adjunct but heterogeneity limits conclusions
Momosaki rPMS pilot (2015) and Hwang review (2022)	rPMS/rPMS+rehab showed physiological and functional swallowing improvements; protocols varied; evidence preliminary
Telerehabilitation review (Nordio 2018)	Very limited evidence; one study showed improved adherence; clinical efficacy vs face-to-face not established
Cochrane swallowing therapy update (Bath et al 2018)	41 trials: no effect on death/dependency; probable reduction in length of stay; may reduce dysphagia and chest infections; evidence variable quality
Mirror therapy meta-analysis (He et al 2022)	5 RCTs pooled: improved clinical effectiveness, water swallowing test, reduced pneumonia; small trials, all from China
Pharyngeal motor cortex stimulation (Michou 2012)	PAS induced cortical excitability and improved swallowing in chronic stroke dysphagia
Noninvasive brain stimulation network/meta-analyses (Li 2021; Xie 2022)	NIBS (rTMS, tDCS) improved multiple swallowing outcomes; rTMS ranked superior to tDCS; study heterogeneity noted
Various small pilot and case series (electrical stimulation, NMES, PES, BTX)	Multiple small studies report improvement in swallowing metrics but require larger RCTs for definitive recommendations

Definitions

Term	Definition
POEM	Per-oral endoscopic myotomy — endoscopic technique to perform myotomy of esophageal muscle fibers and LES via submucosal tunneling.
LHM	Laparoscopic Heller myotomy — surgical myotomy of LES, often with a fundoplication.
Eckardt score	Clinical symptom score for achalasia assessing dysphagia, regurgitation, chest pain and weight loss; lower scores indicate fewer symptoms.
LES	Lower esophageal sphincter.
GERD	Gastroesophageal reflux disease; may be documented symptomatically, endoscopically as esophagitis, or by pH monitoring.
PD	Pneumatic dilation for achalasia.
PAS	Paired associative stimulation, peripheral pharyngeal electrical combined with cortical stimulation.
rTMS	Repetitive transcranial magnetic stimulation, a non-invasive brain stimulation technique.
OES	Self-expanding metal stent (SEMS) — commonly used for palliation of malignant esophageal strictures.
NMES	Neuromuscular electrical stimulation applied transcutaneously to anterior neck to facilitate swallowing musculature.
PES	Pharyngeal electrical stimulation via intraluminal trans-nasal catheters to stimulate pharynx for neurogenic dysphagia.
tDCS	Transcranial direct current stimulation, non-invasive brain stimulation technique used to modulate cortical excitability.
Swallow STRONG	Intensive multi-disciplinary oropharyngeal strengthening program employing device-facilitated isometric progressive resistance therapy for dysphagia.
SEMS	Self-expanding metal stent used for palliation of malignant dysphagia; safer and more effective than plastic tubes per systematic review.
FOIS	Functional Oral Intake Scale — measures oral intake; used to assess improvement with therapies like NMES.
EndoFLIP	Endoluminal Functional Lumen Imaging Probe — device to measure EGJ distensibility intra-operatively during POEM.
EVD	Esophagogastroduodenoscopy (EGD) — diagnostic endoscopy used in evaluation of dysphagia and post-procedure monitoring.
VFSS/VDF	Video fluoroscopic swallowing study (VFSS) / videofluoroscopy (VDF) — instrumental assessments of swallowing function.

OpenPayer

Dysphagia Therapy