CurrentBaylor Scott & White Health PlanPolicy 228

Peroral Endoscopic Myotomy (POEM) for Esophageal Achalasia

Customize your policy alerts

Sign up for baylor_scott_and_white_health_plan Policy 228 alerts

Get alerted when Policy 228 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 consideration for POEM in adults with esophageal achalasia, subject to applicable benefit documents, plan-specific rules, and federal or Texas Medicaid guidance.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyPeroral Endoscopic Myotomy (POEM) for Esophageal Achalasia

Policy CodePolicy 228

Change TypeRevised inclusion criteria

Effective DateSep 1, 2026

Last ReviewJul 23, 2026

Next Review DateJul 23, 2027

Key ActionDocument the member's age, achalasia type and diagnosis by esophageal manometry, Eckardt symptom score, and completion of upper endoscopy, timed barium esophagram, and high-resolution manometry.

SourceLink

POLICY UPDATE CHANGES

The policy's inclusion criteria were updated in the latest review.

18+Minimum member age

I, II, IIIEligible achalasia types

>= 3Required Eckardt score

3Required diagnostic studies

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.

CurrentBaylor Scott & White Health PlanPolicy 228

Peroral Endoscopic Myotomy (POEM) for Esophageal Achalasia

Customize your policy alerts

Sign up for baylor_scott_and_white_health_plan Policy 228 alerts

Get alerted when Policy 228 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 consideration for POEM in adults with esophageal achalasia, subject to applicable benefit documents, plan-specific rules, and federal or Texas Medicaid guidance.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyPeroral Endoscopic Myotomy (POEM) for Esophageal Achalasia

Policy CodePolicy 228

Change TypeRevised inclusion criteria

Effective DateSep 1, 2026

Last ReviewJul 23, 2026

Next Review DateJul 23, 2027

SourceLink

POLICY UPDATE CHANGES

The policy's inclusion criteria were updated in the latest review.

18+Minimum member age

I, II, IIIEligible achalasia types

>= 3Required Eckardt score

3Required diagnostic studies

Medical Necessity Criteria

POEM for Esophageal Achalasia

POEM may be considered medically necessary when ALL of the following are met.

Medical-necessity criteria

Member and diagnosis
- Age: Member is age 18 years or older.>= 18 years
- Achalasia diagnosis: Member has achalasia type I, II, or III diagnosed using esophageal manometry.Types I, II, or III
  Diagnosis must use esophageal manometry.
- Symptom severity: Member has an Eckardt symptom score of at least 3.>= 3
Comprehensive diagnostic workup
- Upper endoscopy has been performed.
- Timed barium esophagram has been performed.
- High-resolution manometry has been performed.

POEM is contraindicated in members with severe erosive esophagitis, significant coagulation disorders, liver cirrhosis with portal hypertension, or prior therapy that may compromise the integrity of the esophageal mucosa or cause submucosal fibrosis, including radiation, endoscopic mucosal resection, or radiofrequency ablation. Previous achalasia treatments, such as pneumatic balloon dilation, botulinum toxin injection, or surgical myotomy, are not themselves contraindications to POEM.

POEM for any indication other than esophageal achalasia is considered experimental, investigational, and unproven.

Billing and Eligibility Codes

Covered CPT CodesCPTCovered

43497

Lower esophageal myotomy, transoral (ie, peroral endoscopic myotomy [POEM])

ICD10 Not coveredICD-10Not Covered

K22.0

Achalasia of cardia

Member Age

Minimum age18 years

RequirementMember is age 18 years or older

Applies toMembers considered for POEM for esophageal achalasia

Eckardt Symptom Score

Required scoreAt least 3

Clinical measureEckardt symptom score

Policy roleRequired criterion for POEM to be considered medically necessary

Documentation and Review Requirements

Documentation Required

Required Clinical Documentation

Document that the member meets the required clinical criteria for POEM, including age, achalasia diagnosis and type confirmed by esophageal manometry, Eckardt symptom score, and comprehensive diagnostic workup.

Age 18 years or older
Achalasia type I, II, or III diagnosed using esophageal manometry
Eckardt symptom score of at least 3
Comprehensive diagnostic workup including upper endoscopy, timed barium esophagram, and high-resolution manometry

Documentation Required

Contraindication and Prior-Treatment Review

Before requesting POEM, document review of contraindications and the member’s prior achalasia treatment history. Prior pneumatic balloon dilation, botulinum toxin injection, or surgical myotomy are not contraindications to POEM; however, therapies that may compromise the esophageal mucosa or cause submucosal fibrosis must be specifically assessed.

Document the contraindication assessment and relevant prior treatment history

Clinical Background

Peroral Endoscopic Myotomy (POEM) is a less invasive alternative to laparoscopic myotomy for esophageal achalasia. Using a natural-orifice transmural endoscopic approach, an endoscope is passed through the esophagus, a submucosal tunnel is created, and muscle fibers in the lower esophagus and proximal stomach are divided. POEM, laparoscopic Heller myotomy, and pneumatic dilation are effective therapies for type I and II achalasia; treatment selection is informed by patient and disease characteristics, patient preferences, and local expertise. POEM is described as the preferred treatment for type III achalasia, and patients should be counseled about the increased risk of postprocedure reflux.

Key Definitions

Peroral Endoscopic Myotomy (POEM)

TechniqueNatural-orifice transmural endoscopic surgery (NOTES)

Access routeAn endoscope is passed through the esophagus

ProcedureA tunnel is created to access the lower esophagus, and muscle fibers in the lower esophagus and proximal stomach are cut

Eckardt Symptom Score

DefinitionA symptom score used to assess symptoms in members being considered for POEM

Required thresholdAt least 3

Medical-necessity role