CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Peroral Endoscopic Myotomy (POEM) and Gastric POEM (G-POEM) Coverage Policy

This policy governs coverage determinations for POEM (for esophageal achalasia) and G-POEM (for gastroparesis) for Blue Cross Blue Shield - Rhode Island members, describing medical necessity and noncoverage positions for Medicare Advantage and commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPeroral Endoscopic Myotomy (POEM) and Gastric POEM (G-POEM) Coverage Policy

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateMar 1, 2024

Next Review DateN/A

Key ActionDo not submit claims for POEM (CPT 43497) or G-POEM as they are considered not covered or not medically necessary per product.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

43497Not-covered CPT

18/100kAchalasia prevalence

61%-75%G-POEM success range

1%Perforation risk

>70References cited

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yesIncludes RCTs/guidelines

Coverage determinations and policy scope

Coverage stance for POEM and G-POEM

Coverage determinations by product:

Medicare Advantage - POEM: Peroral endoscopic myotomy is considered not covered as treatment for pediatric and adult esophageal achalasia because the evidence is insufficient to determine the effects of the technology on health outcomes.

Medicare Advantage - G-POEM: Gastric peroral endoscopic myotomy is considered not covered as a treatment for gastroparesis because the evidence is insufficient to determine the effects of the technology on health outcomes.

Commercial Products - POEM: Peroral endoscopic myotomy is considered not medically necessary as treatment for pediatric and adult esophageal achalasia because the evidence is insufficient to determine the effects of the technology on health outcomes.

Commercial Products - G-POEM: Gastric peroral endoscopic myotomy is considered not medically necessary as a treatment for gastroparesis because the evidence is insufficient to determine the effects of the technology on health outcomes.

Benefits and coverage for procedures described in this policy may vary by group contract. Refer to the member's Benefit Booklet / Evidence of Coverage or Subscriber Agreement to determine whether a specific service is covered for that member.

Services that are determined to be not medically necessary or that are non-covered benefits are excluded from coverage unless the member has agreed in writing to self-pay. Providers may not bill members for services determined to be not medically necessary unless the member has been informed and has signed a written agreement to continue treatment at their own expense. For member-specific eligibility or benefit questions, contact the provider call center; the member's subscriber agreement, member certificate, or employer agreement supersedes this medical policy.

For Commercial Products, both peroral endoscopic myotomy (POEM) and gastric peroral endoscopic myotomy (G-POEM) are considered not medically necessary because the evidence is insufficient to determine their effects on health outcomes. CPT code 43497 (Lower esophageal myotomy, transoral [POEM]) is listed as not covered / not medically necessary.

Services that the plan determines to be not medically necessary may be denied. This policy excerpt does not provide additional specific criteria defining not medically necessary determinations beyond the coverage statements; benefit verification and prior authorization guidance should be obtained from the member's contract and by contacting the provider call center as needed.

Billing codes and coverage status

Not covered / Not medically necessary codesCPTNot Covered

43497

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

Prior authorization, benefit verification, and denial risk

Prior Authorization

Prior authorization: Not applicable.

Note

Benefit Verification

Benefits may vary between groups and contracts. Refer to the member's Benefit Booklet / Evidence of Coverage or Subscriber Agreement for applicable coverage and benefit details.

Note

Benefit and Eligibility Verification

For member-specific eligibility or benefit questions, contact the provider call center.

Clinical background and context

Achalasia is a primary esophageal motility disorder characterized by loss of neurons in the esophageal myenteric plexus and impaired peristalsis, leading to progressive dysphagia, regurgitation, and risk of complications. Peroral endoscopic myotomy (POEM) is an endoscopic submucosal tunneling procedure that performs a myotomy of the lower esophageal sphincter to improve swallowing. POEM is presented in the literature as an alternative to established treatments such as pneumatic dilation and laparoscopic Heller myotomy, but the policy concludes the evidence is insufficient to establish its effect on health outcomes for pediatric and adult achalasia.

Procedure definitions

POEM — key definition and points

DefinitionPeroral endoscopic myotomy (POEM) — an endoscopic submucosal tunneling procedure performed via the oral natural orifice to myotomize the lower esophageal sphincter (LES) to improve swallowing in patients with achalasia.

Indication contextIntended as a less invasive alternative to surgical myotomy for treatment of esophageal achalasia (reduces number of incisions and overall invasiveness).

Comparative evidenceSystematic reviews and randomized trials compare POEM with pneumatic dilation and laparoscopic Heller myotomy; referenced literature includes meta-analyses and RCTs evaluating symptomatic and physiologic outcomes.

Clinical considerationsUsed for pediatric and adult achalasia; outcomes assessed include symptom improvement, physiologic measures, and procedure-related morbidity.

G-POEM (Gastric POEM) — definition and intent

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPeroral Endoscopic Myotomy (POEM) and Gastric POEM (G-POEM) Coverage Policy

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateMar 1, 2024

Next Review DateN/A

Key ActionDo not submit claims for POEM (CPT 43497) or G-POEM as they are considered not covered or not medically necessary per product.

SourceLink

On This Page

Denial Risk

Noncoverage / Not Medically Necessary

Medicare Advantage: POEM and G-POEM are considered not covered. Commercial: POEM and G-POEM are considered not medically necessary.

POEM (peroral endoscopic myotomy) — CPT 43497 (procedure not covered / not medically necessary)
G-POEM (gastric peroral endoscopic myotomy) — not covered / not medically necessary

Note

Referenced Standard Treatments

Treatment context: Standard treatments for achalasia include pharmacotherapy (eg, botulinum toxin), pneumatic dilation, and laparoscopic Heller myotomy. These are recognized alternatives to POEM/G-POEM when clinically appropriate.

Standard achalasia treatments: botulinum toxin injections, pneumatic dilation, laparoscopic Heller myotomy

Denial Risk

Denial and Member Charge Risk

Services determined to be not medically necessary or non-covered may be denied and could result in the provider being restricted from charging the member unless there is a documented, written agreement with the member to proceed at their own expense. Review participation agreements for applicable provisions.

Documentation Required

Provider Actions

Provider actions: Ensure prior authorization status (Not applicable for this policy), verify member benefits and eligibility, document clinical rationale and prior treatments, and obtain a written agreement before providing services that may be non-covered or not medically necessary.

Verify benefits and eligibility prior to scheduling
Document prior treatments and medical necessity rationale in the medical record
Obtain written member agreement before delivering services that may be non-covered

DefinitionGastric peroral endoscopic myotomy (G-POEM) — an endoscopic procedure that creates a submucosal tunnel and performs pyloric myotomy (endoscopic pyloromyotomy) to treat gastroparesis by targeting the pylorus.

IntentIntended to perform the endoscopic equivalent of a pyloroplasty to improve gastric emptying and symptoms in refractory gastroparesis.

Evidence baseEvaluated in prospective trials, meta-analyses, and randomized studies with reported treatment success (based on GCSI reduction) and physiologic improvement; cited trials include international prospective cohorts and RCTs.

G-POEM — supporting references and context

Meta-analyses and RCTsTwo meta-analyses and multiple RCTs and nonrandomized studies have evaluated G-POEM for gastroparesis with reported success rates ranging ~61% to 75% in meta-analyses and at varying follow-up intervals.

Key trials and cohortsInternational prospective trial and several single-center prospective cohorts report mid- and long-term outcomes after G-POEM (references include Vosoughi et al., Hernandez Mondragon et al.).

Comparative studiesRandomized comparisons include G-POEM versus sham or botulinum toxin injection; recent RCTs and pilot sham-controlled trials are cited in the references list.

POEM — comparison to pneumatic dilation and Heller myotomy

Procedural comparisonPOEM is an endoscopic esophageal myotomy for achalasia that is compared in the literature to pneumatic dilation and laparoscopic Heller myotomy as alternative therapeutic options.

Relative invasivenessPOEM uses the oral natural orifice to reduce external incisions compared with surgical Heller myotomy, aiming to be less invasive while achieving myotomy of the LES.

Outcomes and risksComparative studies and meta-analyses evaluate symptomatic and physiologic outcomes and report procedure-related risks; literature cites randomized trials and systematic reviews assessing efficacy and complications (including perforation risk for other modalities).