DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia

Defines Blue Cross Blue Shield - Rhode Island coverage stance for POEM as treatment for pediatric and adult esophageal achalasia across commercial and Medicare lines, and provides clinical background and coding guidance for claims.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPeroral Endoscopic Myotomy for Treatment of Esophageal Achalasia

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJun 1, 2020

Next Review Date

Key ActionFile claims for POEM using unlisted procedure code 43499 and verify member benefits and eligibility with the provider center.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredCoverage stance for POEM (Medicare and Commercial)

43499Unlisted procedure code

10/100kPrevalence (US)

0.6/100kIncidence (US/yr)

40+References cited

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Coverage Determinations

Coverage decision

Covered when ALL of the following are met:

Overall coverage stance: Peroral endoscopic myotomy (POEM) is considered not covered for treatment of pediatric and adult esophageal achalasia under BlueCHiP for Medicare and is considered not medically necessary under Commercial products because evidence is insufficient to determine effects on health outcomes.

Peroral endoscopic myotomy (POEM) is not covered under BlueCHiP for Medicare and is considered not medically necessary for treatment of pediatric and adult esophageal achalasia in Commercial products because the evidence is insufficient to determine effects on health outcomes.

The policy does not list any explicit clinical exclusion criteria for POEM; no patient-specific contraindications or exclusionary clinical conditions are specified in the reference and administrative sections of this document.

For Commercial products the rationale for deeming POEM not medically necessary is that the available evidence is insufficient to determine the procedure's effects on health outcomes for pediatric and adult esophageal achalasia.

If services are determined to be not medically necessary or are non-covered benefits, providers may not charge the member for those services unless the provider has informed the member and obtained a prior written agreement allowing the member to be responsible for payment.

Coding Guidance

Coding guidanceCPT

43499

Unlisted procedure, esophagus

Provider Actions and Billing

Prior Authorization

Prior Authorization and Claims Filing

Prior authorization is not applicable for this service. Claims for peroral endoscopic myotomy (POEM) must be filed using unlisted procedure code 43499 (Unlisted procedure, esophagus).

Prior authorization: Not applicable
Claims filing: Use CPT 43499 (Unlisted procedure, esophagus)
Coverage determination: POEM is considered not covered / not medically necessary for both Commercial and BlueCHiP for Medicare products per this policy
Benefits may vary by contract; verify member benefits and eligibility prior to service

Denial Risk

Benefit and Eligibility Limits

Peroral endoscopic myotomy (POEM) is considered not covered or not medically necessary for treatment of pediatric and adult esophageal achalasia under the referenced products. Benefits and eligibility are governed by the member's subscriber agreement, Evidence of Coverage, or employer contract and those documents supersede this policy.

Clinical Background

Esophageal achalasia is a primary esophageal motility disorder characterized by degeneration of myenteric neurons and impaired peristalsis, resulting in failure of the lower esophageal sphincter to relax. Clinical manifestations include progressive dysphagia for solids and liquids, regurgitation, risk of aspiration, chest pain, and weight loss. These physiologic abnormalities and symptoms can lead to complications such as aspiration pneumonia and malnutrition.

Definitions and Procedure Description

Peroral endoscopic myotomy (POEM) — procedure description

Procedure namePeroral endoscopic myotomy (POEM)

ApproachEndoscopic, per-oral (through the mouth) natural orifice entry

Key stepsCreation of a submucosal tunnel in the proximal esophageal mucosa followed by myotomy of the lower esophageal sphincter

Muscle targetedPrimarily the inner circular layer of the lower esophageal sphincter (via submucosal tunnel)

Intended effectReduce dysfunctional LES muscle fibers to improve esophageal emptying

Esophageal achalasia — definition and epidemiology

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPeroral Endoscopic Myotomy for Treatment of Esophageal Achalasia

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJun 1, 2020

Next Review Date

Key ActionFile claims for POEM using unlisted procedure code 43499 and verify member benefits and eligibility with the provider center.

SourceLink

On This Page

BlueCHiP for Medicare: POEM considered not covered
Commercial Products: POEM considered not medically necessary
Member-specific benefit determination required — contact provider center for eligibility and benefit details

Billing Rule

Claims Filing and Benefits Note

File POEM claims using unlisted CPT code 43499 as there is no specific procedure code. Providers should confirm member benefits and whether the service is excluded or non-covered before performing POEM; if a service is non-covered, providers must obtain a written agreement with the member before billing them.

Billing code: CPT 43499 — Unlisted procedure, esophagus
If service is determined non-covered/not medically necessary, do not bill the member unless a written, advance agreement is in place
Verify eligibility and benefits with the payer prior to scheduling the procedure

Note

Alternative Treatments

Alternative, established treatment options for achalasia include pneumatic dilation, laparoscopic Heller myotomy, and pharmacotherapy such as botulinum toxin injections. Pneumatic dilation and Heller myotomy are considered standard treatments with higher success rates and longer-term efficacy compared with pharmacotherapy, but carry an approximately 1% risk of perforation. POEM is a novel endoscopic approach and differs technically from laparoscopic Heller myotomy.

Standard alternatives: pneumatic dilation; laparoscopic Heller myotomy
Pharmacologic option: botulinum toxin injection
Risk note: Heller myotomy and pneumatic dilation have ~1% perforation risk

Step Therapy

There are no step therapy requirements specified for POEM in this policy. Providers should follow standard clinical pathways and verify any plan-specific utilization management rules that might apply.

Step therapy: None specified in this policy
Providers should check plan-specific requirements for any prior conservative therapy or other utilization management rules

Esophageal achalasia is a motility disorder characterized by reduced numbers of neurons in the esophageal myenteric plexuses and reduced peristaltic activity, causing difficulty swallowing and risk of regurgitation, aspiration, esophagitis, ulceration, and weight loss.

Estimated U.S. prevalenceApproximately 10 cases per 100,000

Estimated U.S. incidenceApproximately 0.6 cases per 100,000 per year

Common clinical consequencesDysphagia, regurgitation, coughing, choking, aspiration pneumonia, esophagitis, ulceration, weight loss

POEM — brief descriptor and relation to evidence

Short descriptorPOEM is an endoscopic procedure developed to perform esophageal myotomy via a submucosal tunnel to cut the inner circular lower esophageal sphincter muscles as a less invasive alternative to laparoscopic Heller myotomy.

Relation to referenced evidencePolicy cites multiple case series and comparative studies, including single-center series up to 500 patients and multicenter reports; 40+ references are included in the document.

Complications noted in literatureReported complications are generally low; referenced studies describe durable long-term results with low complication rates (see cited series).

Comparative pointPOEM differs from laparoscopic Heller myotomy by cutting only the inner circular muscle layer endoscopically rather than dividing both circular and longitudinal layers surgically.