Modifiedblue cross blue shield - michiganPolicy N/A

Peroral endoscopic myotomy (POEM) and Gastric POEM (G-POEM) coverage

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Establishes coverage criteria, inclusions and exclusions for POEM for achalasia and G-POEM for medically refractory gastroparesis, and notes effective dates and multidisciplinary treatment planning requirements; affects providers submitting claims to Blue Cross Blue Shield of Michigan.

Policy Summary

Payerblue cross blue shield - michigan

PolicyPeroral endoscopic myotomy (POEM) and Gastric POEM (G-POEM) coverage

Policy CodePolicy N/A

Change TypeEstablished coverage for POEM and G-POEMmultidisciplinary planning requirement added

Effective DateSept. 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when criteria are met and document diagnostic confirmation, symptom thresholds, prior conservative therapy, and multidisciplinary team agreement.

SourceLink

POLICY UPDATE CHANGES

Peroral endoscopic myotomy (POEM) for achalasia is established and may be considered when specified criteria are met, effective Sept. 1, 2025.

Gastric peroral endoscopic myotomy (G-POEM) for medically refractory gastroparesis is established and may be considered when specified criteria are met, effective Sept. 1, 2025.

POEM and G-POEM require the treatment plan to be agreed upon by a multidisciplinary team with at least two specialists.

BorgWarner will join Blue Cross Blue Shield of Michigan as of Jan. 1, 2026 with Health Reimbursement Account plans and a Health Savings Account plan.

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Modifiedblue cross blue shield - michiganPolicy N/A

Peroral endoscopic myotomy (POEM) and Gastric POEM (G-POEM) coverage

Customize your policy alerts

Sign up for all blue cross blue shield - michigan policy alerts

Know when blue cross blue shield - michigan releases new policies or updates existing guidance.

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Policy Summary

Payerblue cross blue shield - michigan

PolicyPeroral endoscopic myotomy (POEM) and Gastric POEM (G-POEM) coverage

Policy CodePolicy N/A

Change TypeEstablished coverage for POEM and G-POEMmultidisciplinary planning requirement added

Effective DateSept. 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when criteria are met and document diagnostic confirmation, symptom thresholds, prior conservative therapy, and multidisciplinary team agreement.

SourceLink

POLICY UPDATE CHANGES

Peroral endoscopic myotomy (POEM) for achalasia is established and may be considered when specified criteria are met, effective Sept. 1, 2025.

Gastric peroral endoscopic myotomy (G-POEM) for medically refractory gastroparesis is established and may be considered when specified criteria are met, effective Sept. 1, 2025.

POEM and G-POEM require the treatment plan to be agreed upon by a multidisciplinary team with at least two specialists.

BorgWarner will join Blue Cross Blue Shield of Michigan as of Jan. 1, 2026 with Health Reimbursement Account plans and a Health Savings Account plan.

Sept. 1, 2025effective date for POEM and G-POEM coverage

>=18minimum age for POEM and G-POEM

>=3Eckardt score threshold

>20% at 4hGES retention requirement

Multidisciplinary teamrequired consensus

71882affected group number

Coverage Criteria for POEM and G-POEM

POEM (achalasia) — Initial therapy

POEM for the treatment of achalasia is covered when ALL of the following are met

POEM inclusion criteria: The individual is aged 18 years or older; The individual has been diagnosed with achalasia, type I, II or III; The diagnosis of achalasia has been confirmed by a positive esophageal manometry, esophagogastroduodenoscopy (EGD) and barium swallow (contrast esophagram); Eckardt score >= 3; The treatment plan to use POEM has been agreed upon by a multidisciplinary team of physicians including at least 2 specialists after considering all relevant treatment approaches and determined to be the best treatment option.

Multidisciplinary team example: GI medicine and surgeon.

G-POEM (medically refractory gastroparesis) — Initial therapy

G-POEM for the treatment of medically refractory gastroparesis is covered when ALL of the following are met

G-POEM inclusion criteria: The individual is aged 18 years or older; The individual has moderate to severe symptoms with intractable nausea and vomiting dominant on the Gastroparesis Cardinal Symptom Index (GCSI); EGD has been performed to confirm no mechanical gastric outlet obstruction; Solid-phase gastric emptying scan confirms delayed gastric emptying with retention > 20% at 4 hours; The individual has had an inadequate response to conservative treatment of gastroparesis, including dietary modification and a trial of at least one medication (e.g., prokinetic or antiemetic); The treatment plan to use G-POEM has been agreed upon by a multidisciplinary team (motility specialists, advanced endoscopists) with extensive experience in treating refractory gastroparesis after considering all relevant treatment approaches and determined to be the best option.

Requires multidisciplinary team with extensive experience.

POEM and G-POEM have specific exclusions that, if present, make these procedures inappropriate. For POEM the policy lists severe cardiopulmonary disease, esophageal malignancy, history of prior esophageal therapy (for example esophageal surgery, esophageal radiation, mucosal resection, or radiofrequency ablation), significant uncorrectable coagulopathy, severe erosive esophagitis, and liver cirrhosis with portal hypertension as exclusions. For G-POEM the policy excludes patients with mechanical obstruction of the gastric outflow, contraindications to anesthesia or endoscopy, most cases of postinfectious gastroparesis, and notes that individuals with opioid dependence should be weaned and have gastric emptying re-evaluated prior to considering G-POEM.

Administrative group benefit change excerpts in this notice do not include clinical coverage criteria, exclusions, or medical necessity statements for the group-specific items described; the group change text is administrative in nature (onboarding, plan types, vendor drug coverage) and does not alter the clinical criteria set forth for POEM or G-POEM in the policy.

Procedures performed when the policy's inclusion criteria are not met — for example when required diagnostic confirmation is absent, symptom thresholds are not reached, or prior conservative therapy (for G-POEM) has not been attempted — are identified in the policy as not meeting established coverage criteria and therefore are at risk for denial.

Coding and Diagnostic Thresholds

Payable/Updated Procedure Codes for POEM/G-POEMCPT

43497	POEM — listed in updates to payable procedures
43499	POEM — unlisted procedure code referenced

inv-07: Eckardt score — threshold value for POEM eligibility

Eckardt score threshold>= 3 indicates active achalasia and meets symptom threshold for POEM eligibility

Scale range4-item self-report scale, items scored 0–3, maximum 12

Domains assessedWeight loss, chest pain, regurgitation, dysphagia

inv-08: Solid-phase gastric emptying scan retention — threshold for G-POEM eligibility

Gastric emptying retention threshold> 20% retention at 4 hours on solid-phase gastric emptying scan

Test requiredSolid-phase gastric emptying scan (GES) confirming delayed gastric emptying

Prior Authorization, Documentation, and Administrative Actions

Prior Authorization

Prior Authorization — None Specified

Prior authorization: Not specified in this section. The source text does not state any prior authorization requirements, procedures, or submission instructions for POEM or G‑POEM. Providers should not assume an authorization process is described here and should verify payer-specific prior authorization policies separately.

Prior authorization not mentioned; none specified in source
No explicit authorization or denial triggers provided

Step Therapy

Conservative Therapy Requirement for G‑POEM

Conservative therapy requirement for G‑POEM is stated: G‑POEM is for medically refractory gastroparesis after inadequate response to conservative treatment including dietary modification and a trial of at least one prokinetic (e.g., erythromycin). No additional step‑therapy or prior step count rules are provided.

Conservative therapy required prior to G‑POEM (dietary modification + trial of ≥1 prokinetic)

Clinical Background

Achalasia is a primary esophageal motility disorder diagnosed using esophageal manometry, esophagogastroduodenoscopy (EGD), and barium swallow. Symptom severity and treatment response are most commonly measured with the Eckardt symptom score, a 4-item patient-reported scale (weight loss, chest pain, regurgitation, dysphagia) with item scores 0–3 and a maximum of 12; an Eckardt score ≥ 3 indicates active achalasia.

Definitions and Symptom Scores

inv-70: Eckardt score — definition and scoring (ESS)

DefinitionEckardt symptom score (ESS): a 4-item self-report scale assessing weight loss, chest pain, regurgitation, and dysphagia

Item scoringEach item scored 0 to 3

Total score rangeMaximum score 12

Actionable thresholdScore >= 3 indicates active achalasia (meets symptom criterion for POEM)

inv-71: GCSI — Gastroparesis Cardinal Symptom Index definition

DefinitionGastroparesis Cardinal Symptom Index (GCSI): a patient-reported instrument measuring severity of gastroparesis symptoms with emphasis on intractable nausea and vomiting

Policy Summary

Payerblue cross blue shield - michigan

PolicyPeroral endoscopic myotomy (POEM) and Gastric POEM (G-POEM) coverage

Policy CodePolicy N/A

Change TypeEstablished coverage for POEM and G-POEMmultidisciplinary planning requirement added

Effective DateSept. 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when criteria are met and document diagnostic confirmation, symptom thresholds, prior conservative therapy, and multidisciplinary team agreement.

SourceLink

On This Page

PurposeUsed to confirm delayed gastric emptying prior to G-POEM for medically refractory gastroparesis

No step therapy rules (e.g., prior authorization or mandated sequence) are specified

Documentation Required

Documentation — Diagnostic and Clinical Confirmation Required

Required documentation described in the policy: for POEM (achalasia) confirmatory diagnostics include esophageal manometry, EGD, and barium swallow; Eckardt score ≥3; multidisciplinary team agreement. For G‑POEM (gastroparesis) required documentation includes EGD to exclude mechanical obstruction, a solid‑phase gastric emptying scan with >20% retention at 4 hours, evidence of moderate–severe symptoms (GCSI with dominant nausea/vomiting), prior conservative therapy trial, and multidisciplinary team agreement.

POEM: esophageal manometry + EGD + barium swallow; Eckardt score ≥3; age ≥18; multidisciplinary team plan
G‑POEM: EGD to exclude mechanical obstruction; gastric emptying scan (>20% retention at 4 hours); GCSI documenting moderate–severe symptoms with dominant nausea/vomiting; age ≥18; documentation of inadequate response to conservative therapy

Denial Risk

Potential Denial Triggers (Implied)

Potential claim-denial triggers are not explicitly listed in this section, but the inclusion/exclusion criteria imply likely denial reasons: age <18, lack of required confirmatory testing (manometry/EGD/barium for achalasia; GES and EGD for gastroparesis), Eckardt score <3 for achalasia, failure to document inadequate conservative therapy for G‑POEM, and presence of listed exclusions (e.g., mechanical obstruction, severe comorbidity, prior esophageal therapy).

Denial risk if required diagnostics are missing or thresholds not met (Eckardt <3, GES ≤20% retention at 4 hours)
Denial risk if conservative therapy trial for gastroparesis not documented
Denial risk if exclusion criteria present (e.g., mechanical obstruction, severe cardiopulmonary disease, esophageal malignancy)

Note

Administrative Identifiers and Group Info

Administrative identifiers and group information are present in the source but are unrelated to clinical authorization: Group number 71882 with alpha prefixes BIM (PPO) and XYX (Medicare primary); platform: NASCO classic. This section provides employer/group enrollment details (BorgWarner joining BCBSM) and vendor prescription drug notes — no provider action or authorization procedure described here.

Group number: 71882
Alpha prefixes: BIM (PPO), XYX (Medicare primary)
Platform: NASCO classic
Administrative/employer group information only — no clinical documentation or authorization steps provided

Dominant symptom for G-POEM consideration

Intractable nausea and vomiting dominant on the GCSI

Use in policyGCSI symptom predominance is required as part of inclusion criteria for G-POEM