ModifiedAmeriHealth CaritasPolicy CCP.1199

Peroral endoscopic myotomy (POEM)

Customize your policy alerts

Sign up for AmeriHealth Caritas Policy CCP.1199 alerts

Get alerted when Policy CCP.1199 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs medical necessity and coverage criteria for peroral endoscopic myotomy (POEM) procedures for esophageal achalasia and gastric POEM for refractory gastroparesis, including contraindications, alternative services, and investigational indications, for AmeriHealth Caritas members.

Policy Summary

PayerAmeriHealth Caritas

PolicyPeroral endoscopic myotomy (POEM)

Policy CodePolicy CCP.1199

Change TypeRevised coverage indications and added sections

Effective DateJan 1, 2025

Last ReviewNov 1, 2025

Next Review DateMar 1, 2027

Key ActionObtain prior authorization with documentation of comprehensive diagnostic workup and standardized 4-hour gastric emptying testing when applicable.

SourceLink

POLICY UPDATE CHANGES

Coverage indications updated to incorporate 2024–2025 guideline updates, standardized gastric emptying testing protocols, and symptom duration thresholds.

The coverage indications for peroral endoscopic myotomy were revised to incorporate updated evidence-based guidance emphasizing a comprehensive diagnostic evaluation, standardized gastric emptying testing protocols, and symptom duration thresholds.

A new section on non-achalasia spastic disorders was added.

Integrated a meta-analysis comparing long-term outcomes for achalasia treatment.

91%clinical success (achalasia)

92.8%clinical success (G-POEM)

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

ModifiedAmeriHealth CaritasPolicy CCP.1199

Peroral endoscopic myotomy (POEM)

Customize your policy alerts

Sign up for AmeriHealth Caritas Policy CCP.1199 alerts

Get alerted when Policy CCP.1199 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerAmeriHealth Caritas

PolicyPeroral endoscopic myotomy (POEM)

Policy CodePolicy CCP.1199

Change TypeRevised coverage indications and added sections

Effective DateJan 1, 2025

Last ReviewNov 1, 2025

Next Review DateMar 1, 2027

Key ActionObtain prior authorization with documentation of comprehensive diagnostic workup and standardized 4-hour gastric emptying testing when applicable.

SourceLink

POLICY UPDATE CHANGES

Coverage indications updated to incorporate 2024–2025 guideline updates, standardized gastric emptying testing protocols, and symptom duration thresholds.

A new section on non-achalasia spastic disorders was added.

Integrated a meta-analysis comparing long-term outcomes for achalasia treatment.

91%clinical success (achalasia)

92.8%clinical success (G-POEM)

23.9%post-POEM reflux

7.4%G-POEM adverse events

95.2%technical success (diverticula)

Coverage Criteria for POEM and G-POEM

POEM for esophageal achalasia — Covered when ALL following are met

Peroral endoscopic myotomy is medically necessary for esophageal achalasia when ALL of the following criteria are met:

Comprehensive diagnostic workup: A comprehensive diagnostic workup has been completed, including upper endoscopy, high-resolution manometry, and a timed barium esophagram (functional luminal impedance planimetry may be used as an adjunct if diagnosis is equivocal)

(Yang, 2024)

Treatment history: Patient is either treatment-naïve or has recurrent/persistent achalasia following pneumatic dilation, laparoscopic Heller myotomy, or prior peroral endoscopic myotomy.

(Vaezi, 2020; Yang, 2024)

Manometric subtype: Diagnosis of esophageal achalasia type I, II, or III based on high-resolution manometry.

Type III is generally preferred for POEM due to ability to perform a longer tailored myotomy.

Gastric POEM (G-POEM) for refractory gastroparesis — Covered when ALL following are met

Gastric POEM (G-POEM) is medically necessary for adults (≥18 years) with medically refractory gastroparesis when ALL of the following criteria are met:

Age: Member is age 18 years or older.

(Staller, 2025)

Anatomic exclusion of obstruction: Esophagogastroduodenoscopy (EGD) confirms no mechanical gastric outlet obstruction.

(Camilleri, 2022)

Objective delayed gastric emptying: A standardized four-hour solid‑phase gastric emptying scintigraphy (Eggbeaters meal) demonstrates delayed emptying with ≥20% gastric retention at 4 hours (criterion for G-POEM candidacy).>=20% at 4 hours

(Staller, 2025)

Revised coverage criteria (summary) — Covered when ALL of the following are met

Covered when ALL of the following are met:

Updated diagnostic and testing requirements: Comprehensive diagnostic evaluation and standardized gastric emptying testing protocols are documented in the medical record.Symptom duration thresholds per updated guidelines

Coverage indications were revised to incorporate updated guideline recommendations and symptom duration requirements; see full policy for numeric thresholds and test timing.

Per the policy, POEM is considered investigational and not medically necessary for treatment of esophageal diverticula. The policy notes that although D-POEM has reported technical and clinical success in selected series, the procedure is classified as investigational/not clinically proven and therefore not covered for esophageal diverticula (Mandavdhare, 2021).

The policy also states that POEM for gastroparesis in pediatric populations (age <18 years) is investigational and not medically necessary, and therefore not covered for patients under 18 (Staller, 2025).

This portion of the updated policy summarizes broadened coverage indications and revised diagnostic expectations but does not enumerate additional explicit exclusions within the cited text. The policy update emphasizes incorporation of recent guideline recommendations, standardized testing protocols, and symptom-duration thresholds into coverage criteria; consult the full policy text for the complete list of exclusions and specificity around any procedure-specific limitations.

The policy explicitly states that gastric POEM (G-POEM) for patients under age 18 years is not medically necessary. Pediatric gastroparesis is therefore excluded from coverage for G-POEM in this policy (Staller, 2025).

The section cited here provides revised coverage indications and describes changes to diagnostic and testing requirements but does not contain explicit not medically necessary statements within the excerpt. For definitive not-medically-necessary conditions and exclusions, reviewers and providers should refer to the full policy language where NMN determinations are listed in detail.

Affected Codes and Diagnostic Cutoffs

Affected codesmixed

affected codes

Codes referenced by policy for prior authorization and billing (document lists 'affected codes' placeholder)

inv-09: 4-hour gastric emptying retention — diagnostic threshold for G-POEM candidacy

Gastric emptying retention threshold>=20% retention at 4 hours on a standardized 4-hour Eggbeaters meal study

Alternative diagnostic cutoffs citedGuideline diagnostic cutoffs also reference >10% retention at 4 hours with Eggbeaters meal or >25% with a real egg meal (not used as G-POEM candidacy threshold)

Test required for candidacyStandardized 4-hour gastric emptying scintigraphy (Eggbeaters meal) must be documented

Prior Authorization, Documentation, and Provider Steps

Prior Authorization

Prior authorization: document diagnostic criteria and conservative therapies

Prior authorization is required and requests must document that diagnostic criteria and indicated conservative therapies have been met — including manometry-defined achalasia subtyping and completion of the comprehensive diagnostic workup (upper endoscopy, high-resolution manometry, timed barium esophagram; FLIP may be used as an adjunct if equivocal). For gastric POEM, include documentation of a standardized 4‑hour Eggbeaters gastric emptying study showing the required retention threshold and evidence of failure of medical therapy.

Documented high-resolution manometry confirming achalasia subtype.
Upper endoscopy and timed barium esophagram completion (FLIP as adjunct if equivocal).
For G-POEM: standardized 4-hour Eggbeaters study with percent retention at 4 hours and record of failed medical therapies.

Prior Authorization

Prior authorization must include updated diagnostic testing documentation

Per the revised policy, prior authorization must include documentation of the diagnostic evaluation and testing consistent with updated guideline-based requirements when requesting authorization for POEM.

Clinical Background and Context

Achalasia is a chronic esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation, increased LES pressure, and absent distal peristalsis; diagnosis relies on high-resolution manometry with Chicago Classification subtyping. Peroral endoscopic myotomy (POEM) is an endoscopic myotomy that creates a submucosal tunnel and divides circular muscle fibers across the esophagogastric junction to relieve outflow obstruction. The policy notes that POEM is an established, minimally invasive therapeutic option for achalasia and that recent guideline updates (2024–2025) were integrated into the coverage indications to clarify diagnostic evaluation, testing protocols, and symptom-duration thresholds.

Definitions and Classification

inv-19: Eckardt score — 0–12 symptom score details

Score range0–12 total points

Constituent symptomsDysphagia, regurgitation, chest pain, and weight loss (0–3 points each)

Interpretation by stage0–1 = stage 0; 2–3 = stage I; 4–6 = stage II; >6 = stage III

inv-20: Chicago Classification (manometry types) — Type I, II, III descriptions

Type I100% failed peristalsis

Type II100% failed peristalsis with panesophageal pressurization in ≥20% of swallows

Type III

Policy Summary

PayerAmeriHealth Caritas

PolicyPeroral endoscopic myotomy (POEM)

Policy CodePolicy CCP.1199

Change TypeRevised coverage indications and added sections

Effective DateJan 1, 2025

Last ReviewNov 1, 2025

Next Review DateMar 1, 2027

Key ActionObtain prior authorization with documentation of comprehensive diagnostic workup and standardized 4-hour gastric emptying testing when applicable.

SourceLink

On This Page

Symptom severity and duration:

Moderate-to-severe symptoms (typically nausea, vomiting, or postprandial fullness) present for at least 6–12 months; Gastroparesis Cardinal Symptom Index >2 preferred.

Medically refractory: Failure of at least two medical treatments, including at least three months of a prokinetic agent and at least one antiemetic, after medication reconciliation and glycemic optimization when applicable.failure of >=2 meds

(Staller, 2025; Camilleri, 2022)

Attach diagnostic test results and reports that match policy requirements.
Indicate which coverage modification or guideline update supports the request.

Step Therapy

Stepwise treatment considerations: document prior therapies or treatment‑naïve status

POEM may be used in treatment‑naïve achalasia patients or after failed prior interventions; authorization requests should state prior treatments and whether the member is treatment‑naïve or has persistent/recurrent disease after pneumatic dilation, laparoscopic Heller myotomy, or prior POEM.

Indicate prior pneumatic dilation, Heller myotomy, or prior POEM if applicable.
If treatment‑naïve, document rationale per guideline recommendations.

Note

Supply complete diagnostic and management documentation with authorization requests

Provide clear, policy‑aligned documentation of diagnostic findings and prior management steps to support medical necessity determinations for POEM.

Include the specific tests performed and their results.
State symptom duration and prior medical or procedural treatments.

Documentation Required

Required diagnostic documentation: complete diagnostic workup

Authorization and medical records must document completion of a comprehensive diagnostic workup: upper endoscopy (EGD), high‑resolution manometry, and timed barium esophagram (with FLIP allowed as an adjunct if the diagnosis is equivocal). For G‑POEM, include EGD confirming no mechanical outlet obstruction and the standardized 4‑hour Eggbeaters gastric emptying study result.

Upper endoscopy (EGD) report ruling out mechanical obstruction.
High‑resolution manometry report confirming achalasia subtype.
Timed barium esophagram report; FLIP documented if used.
For G‑POEM: 4‑hour Eggbeaters gastric emptying retention result.

Documentation Required

Required clinical documentation: testing, symptom duration, and treatment failures

Clinical documentation must reflect a comprehensive diagnostic evaluation, standardized gastric emptying testing protocols for G‑POEM, and recorded symptom duration (typically 6–12 months for gastroparesis). Include documentation of failure of at least two medical treatments (including ≥3 months of a prokinetic and at least one antiemetic) when applicable.

Record symptom duration (6–12 months preferred for gastroparesis).
Document failure of ≥2 medical treatments, with duration of prokinetic therapy (≥3 months).
Include objective 4‑hour gastric emptying retention percentage for G‑POEM candidacy.

Denial Risk

Contraindications may trigger denial — confirm none are present

Procedures performed in the presence of listed contraindications may be denied. Examples include uncorrected coagulopathy, liver cirrhosis, pregnancy, severe erosive esophagitis, severe pulmonary disease, or inability to undergo endoscopy/anesthesia.

Uncorrected coagulopathy.
Presence of liver cirrhosis.
Pregnancy at time of treatment.
Severe erosive esophagitis.
Severe pulmonary disease or not a candidate for endoscopy/anesthesia.

Denial Risk

Denial risk if required diagnostic/testing or clinical duration evidence is missing

Failure to provide the comprehensive diagnostic evaluation, standardized gastric emptying testing, or documentation of symptom duration and prior treatment failures as required by the revised coverage indications could result in denial of coverage for POEM.

Missing or incomplete high‑resolution manometry, EGD, or timed barium esophagram.
Absent standardized 4‑hour gastric emptying study result for G‑POEM requests.
No documentation of symptom duration or failure of required medical therapies.

No normal peristalsis and premature/spastic contractions in ≥20% of swallows

inv-21: POEM — definition of peroral endoscopic myotomy

DefinitionPeroral endoscopic myotomy (POEM) is an endoscopic procedure creating a submucosal tunnel and performing a myotomy across the esophagogastric junction to cut muscle fibers and relieve obstruction from motility disorders

Technique highlightsInvolves mucosal incision, submucosal tunneling crossing the EGJ, myotomy, and mucosal closure

Indications contextEstablished treatment for esophageal achalasia and adapted variants (eg, G-POEM for pylorus) per guideline-based selection

inv-22: D-POEM — diverticular POEM definition

DefinitionDiverticular POEM (D-POEM) is the application of peroral endoscopic myotomy techniques to treat esophageal diverticular disease, including Zenker's diverticula

Outcomes evidenceReported clinical success for POEM in esophageal diverticula: 87% clinical success and 95.19% technical success (Mandavdhare, 2021)

Comparative effectivenessPOEM demonstrates 13% higher relative clinical effectiveness versus flexible endoscopic septum division in pooled analyses