CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Peroral endoscopic myotomy (POEM) for esophageal achalasia

This policy addresses coverage and medical necessity for POEM as a treatment for pediatric and adult esophageal achalasia for Blue Cross Blue Shield - Rhode Island members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPeroral endoscopic myotomy (POEM) for esophageal achalasia

Policy CodePolicy N/A

Change TypeNo material change

Effective Date06|01|2020

Next Review DateN/A

Key ActionVerify member-specific benefits and eligibility with the provider call center before submitting claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10/100kestimated U.S. prevalence

0.6/100k/yrestimated U.S. incidence

86%1-yr response rate (Heller)

1%perforation risk

500size of cited POEM series

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Not covered / Not medically necessary

Covered when ALL of the following are met:

Policy Coverage Determination: For Medicare Advantage and Commercial Products, POEM is considered not covered / not medically necessary for treatment of pediatric and adult esophageal achalasia as the evidence is insufficient to determine effects on health outcomes.

Statement applies to both pediatric and adult populations per document.

Peroral endoscopic myotomy (POEM) is not covered for the treatment of pediatric and adult esophageal achalasia.

For Commercial Products, POEM is considered not medically necessary, and for Medicare Advantage Plans, POEM is considered not covered for treatment of pediatric and adult esophageal achalasia due to insufficient evidence demonstrating effects on health outcomes.

Services determined to be not medically necessary or otherwise non‑covered are excluded from coverage in accordance with the member's subscriber agreement, certificate, or employer agreement; those documents supersede this medical policy.

If a provider furnishes services that are determined to be not medically necessary (or non‑covered benefits), the provider may not bill the member unless the member has been informed and has provided written agreement in advance to accept financial responsibility; benefits and eligibility vary by contract and should be verified with the provider call center.

Provider Requirements and Recommendations

Prior Authorization

Prior Authorization and Benefit Verification

Prior Authorization: Not applicable. Benefits may vary between groups and contracts; providers should verify member-specific benefits and eligibility by contacting the BCBSRI provider call center prior to rendering services.

Verify member-specific benefits and eligibility with the BCBSRI provider call center before scheduling POEM.
Prior authorization: Not applicable (per policy), but benefit verification is recommended because coverage may vary by contract.

Denial Risk

Coverage Denial and Billing Guidance

Peroral endoscopic myotomy (POEM) is considered not covered / not medically necessary for treatment of pediatric and adult esophageal achalasia under the referenced BCBSRI Medicare Advantage and Commercial product policy. Claims submitted using the unlisted esophagus procedure code (CPT 43499) may be denied if the service is determined to be not medically necessary or non-covered. Providers should follow contract terms regarding billing the member — services determined NMN or non-covered may not be billable to the member unless prior written agreement exists as specified in participation/subscriber documents.

Coverage status: POEM considered not covered / not medically necessary — high risk of claim denial.
Billing code guidance: File claims with unlisted procedure, esophagus (CPT 43499).
Do not bill the member for services determined NMN or non-covered unless you have prior written member agreement per contract terms.

Note

Treatment Context

Standard treatment options for achalasia include botulinum toxin injections, pneumatic dilation, and laparoscopic Heller myotomy. POEM is described as a novel endoscopic procedure distinct from laparoscopic Heller myotomy. Providers should consider these standard treatments and note POEM’s status under this policy when planning care and discussing options with patients.

Standard treatments: botulinum toxin injections, pneumatic dilation, laparoscopic Heller myotomy.
POEM is an alternative novel endoscopic myotomy but is considered not covered/not medically necessary per policy.

Note

Verify Benefits and Eligibility

Providers should verify benefits and eligibility for each member prior to providing services. For member-specific benefit information, contact the BCBSRI provider call center. This policy is informational and not a guarantee of payment; the member's subscriber agreement and employer agreement govern benefits.

Contact the BCBSRI provider call center for member-specific eligibility and benefit verification.
Do not assume coverage based on this policy; verify contract-specific terms.

Clinical Background

Esophageal achalasia is a primary esophageal motility disorder characterized by loss of neurons in the esophageal myenteric plexus leading to reduced peristalsis and impaired relaxation of the lower esophageal sphincter, which results in symptoms such as progressive dysphagia, regurgitation, risk of aspiration, esophagitis, and weight loss. POEM is an endoscopic technique that creates a submucosal tunnel and performs selective myotomy of the inner circular muscle of the lower esophageal sphincter to improve esophageal emptying and reduce obstructive symptoms.

Key Definitions

POEM — definition and brief procedure description

DefinitionPeroral endoscopic myotomy (POEM): an endoscopic procedure performed via the oral route using a submucosal tunnel to selectively cut the inner circular fibers of the lower esophageal sphincter to relieve obstruction.

Procedure steps (brief)Under general anesthesia, an endoscope is tunneled through the proximal esophageal mucosa toward the esophagogastric junction, a submucosal tunnel is created, and a myotomy of the inner circular lower esophageal sphincter muscles is performed.

PurposeTo reduce outflow obstruction at the lower esophageal sphincter and improve esophageal emptying and dysphagia symptoms by cutting dysfunctional circular muscle fibers.

How POEM differs from laparoscopic Heller myotomyPOEM cuts only the inner circular muscle layer via an endoscopic submucosal tunnel, whereas laparoscopic Heller myotomy involves division of both circular and longitudinal muscle layers via laparoscopy.

Achalasia — definition

DefinitionEsophageal achalasia: a primary esophageal motility disorder characterized by loss/reduced numbers of neurons in the esophageal myenteric plexus with reduced peristaltic activity and impaired lower esophageal sphincter relaxation.

Clinical featuresPatients typically have progressive dysphagia for solids and liquids and may develop regurgitation, coughing, choking, aspiration pneumonia, esophagitis, ulceration, and weight loss.

Epidemiology (US estimates)Estimated prevalence about 10 cases per 100,000 and incidence about 0.6 cases per 100,000 per year.

OpenPayer

Peroral endoscopic myotomy (POEM) for esophageal achalasia

Coverage Determination

Billing and Coding

Provider Requirements and Recommendations

Clinical Background

Key Definitions