MA Lower Esophageal Myotomy for Treatment of Achalasia and Gastroparesis (Preauthorization Required)
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Policy governing preauthorization and medical necessity criteria for POEM to treat achalasia and the coverage stance for G-POEM for gastroparesis for BCBS Nebraska members and providers.
Updated and added type I and II achalasia as allowed when criteria is met.
Coverage Criteria
POEM — Medically Necessary Criteria
POEM may be considered reasonable and necessary when ALL the following are met:
All three conditions must be satisfied.
Evidence-informed coverage considerations
Coverage decisions should be informed by established diagnostic confirmation and evidence-based selection among PD, LHM, POEM, and G-POEM as described in guidelines and systematic reviews.
From ACG guideline summary
Balance efficacy vs reflux risk; consider institutional expertise and patient preference
ACG guideline recommendation
Based on Canakis, Stojilkovic, Aziz systematic reviews
Covered Indications (summary)
Covered when policy criteria are met (preauthorization required).
Preauthorization required per policy header; providers must submit procedure-diagnosis code pair via the policy tool for authorization.
Per the policy, G-POEM is considered not reasonable and necessary as a treatment for gastroparesis and for all other indications because its effectiveness has not been established.
The policy notes that botulinum toxin injection is recommended only for patients who are unfit for definitive interventions and that it is not a durable alternative to definitive therapies for achalasia.
There are no additional explicit exclusions listed in the cited portion of the document.
The policy states that POEM is considered not reasonable and necessary when the POEM medical necessity criteria are not all met and for any other indications beyond those specified for achalasia.
Within the provided excerpt there are no standalone statements labelled explicitly as additional “not medically necessary” beyond the POEM and G-POEM determinations already documented.
Coding
| affected codes | The policy includes a Quick Code Search feature for procedure and diagnosis code pairs; specific CPT/ICD codes are not listed in these chunks. |
Provider Actions & Authorization
Preauthorization required for POEM/G-POEM
Preauthorization is required for MA lower esophageal myotomy (POEM/G-POEM) per the policy header; POEM is covered only when all medical necessity criteria are met.
Preauthorization required for lower esophageal myotomy procedures
Lower esophageal myotomy procedures for achalasia and gastroparesis require preauthorization before scheduling or performing the procedure.
Preauthorization required for MA lower esophageal myotomy
Preauthorization is required for MA lower esophageal myotomy when used to treat achalasia and gastroparesis; authorization must be obtained per this policy prior to the procedure.
Authorization required for MA lower esophageal myotomy procedures
Preauthorization is required for MA lower esophageal myotomy procedures for treatment of achalasia and gastroparesis; do not proceed without obtaining authorization.
Preauthorization required — CPT 43497 and related codes
Preauthorization is required for listed procedures including CPT 43497 (transoral lower esophageal myotomy/POEM) and unlisted procedure codes 43499 and 43999; submit matching diagnosis codes via the Quick Code Search for determination.
Select therapy based on achalasia subtype and guidelines
Therapy selection among pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), and POEM should be individualized: PD, LHM, and POEM are considered comparably effective for types I–II, while POEM or tailored surgical myotomy is favored for type III.
- HRM-based subtype classification (I, II, III) should guide selection.
- LHM is generally performed with fundoplication to reduce reflux risk.
Required documentation to establish medical necessity
Documentation submitted for medical necessity must demonstrate the patient is ≥18 years old, has a diagnosis of type I, II, or III achalasia, and an Eckardt symptom score greater than 3.
- Age ≥ 18 years
- Diagnosis: achalasia type I, II, or III (per HRM/Chicago Classification)
- Eckardt symptom score > 3
Submit authorization request per BCBS Nebraska process
Providers must submit an authorization request per BCBS Nebraska procedures to obtain preauthorization for MA lower esophageal myotomy prior to performing the procedure.
Use Quick Code Search for procedure–diagnosis code pairs
Use the policy's Quick Code Search tool to enter the procedure and diagnosis code pair when requesting preauthorization; the tool will indicate approval, denial, or hold for review.
- Enter procedure code first, then diagnosis code, then click 'Add Code Pair'.
- The Quick Code Search will show if the pair is listed in this policy and its status.
Submit procedure and diagnosis code pair for review
Providers must submit both a procedure code and a matching diagnosis code pair for review via the Quick Code Search; both elements are required for preauthorization determination.
- Both a procedure and diagnosis code are required to add a code pair.
- Incomplete code-pair submissions may prevent authorization processing.
Denial risk if POEM criteria are not fully met
POEM/G-POEM procedures will be considered not reasonable and necessary (and are therefore subject to denial) if the policy's POEM criteria are not all met.
- All POEM medical necessity criteria (age ≥18, achalasia type I–III, Eckardt > 3) must be satisfied.
Risk of denial if preauthorization not obtained
Failure to obtain required preauthorization may trigger denial of coverage for the procedure.
Denial risk for MA lower esophageal myotomy without authorization
Preauthorization not obtained may lead to denial of coverage for MA lower esophageal myotomy; do not proceed without prior authorization.
Code-pair verification required to avoid denial or hold
Procedures not submitted with appropriate procedure–diagnosis code pairs via the Quick Code Search may be denied or held for review.
- Use the Quick Code Search to verify that the code pair is listed in the policy.
Quick Code Search will flag missing or nonconforming code pairs
If a procedure and diagnosis code pair is not added or does not meet the policy's requirements, the Quick Code Search may display that the pair will be denied or held for review; providers should confirm pairs before submission.
- Confirm the Quick Code Search dropdown and status after adding the code pair.
Background
Achalasia is a primary esophageal motility disorder caused by progressive loss of myenteric plexus ganglion cells, producing failure of lower esophageal sphincter (LES) relaxation and loss of distal esophageal peristalsis, which typically presents with progressive dysphagia, regurgitation, chest pain, and weight loss. High-resolution manometry (HRM) is the diagnostic gold standard and classifies disease by the Chicago Classification into types I (classic), II (with panesophageal pressurization), and III (spastic), which guides treatment selection; POEM, laparoscopic Heller myotomy, and pneumatic dilation are considered comparably effective for types I–II, with POEM favored for type III.
Definitions
Revision History
Policy updated to explicitly allow treatment of type I and type II achalasia with POEM when the medical necessity criteria are met.
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