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    v1.0.28
    OpenPayerPolicy UpdatesGastroenterologyCareSource Georgia POEM Coverage & Prior Auth Upda…
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    CurrentCareSource GeorgiaPolicy MEDICAL POLICY STATEMENT Date Effective = Date Effective 11/01/2025

    Peroral Endoscopic Myotomy (POEM) — Coverage Criteria

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    This medical policy defines clinical coverage criteria, contraindications, and related guidance for Peroral Endoscopic Myotomy (POEM) for treatment of achalasia for CareSource Georgia members.

    Policy Summary
    PayerCareSource Georgia
    PolicyPeroral Endoscopic Myotomy (POEM) — Coverage Criteria
    Policy CodePolicy MEDICAL POLICY STATEMENT Date Effective = Date Effective 11/01/2025
    Change TypeClinical and operational revisions (symptom threshold, age review)editorial updates
    Effective DateNov 1, 2025
    Last ReviewAug 13, 2025
    Next Review Date
    Key ActionObtain prior authorization and document diagnosis, prior therapies, Eckardt score (≥3), and absence of prior open stomach/esophageal surgery.
    SourceLink
    POLICY UPDATE CHANGES

    Lowered Eckardt symptom score criteria to ≥ 3 to match other lines of business.

    Updated age requirement (members 18 or younger should be reviewed for medical necessity).

    Changed reflux esophagitis terminology to GERD in policy Section D.V.

    Title edited to remove acronym and POEM definition deleted.

    Eckardt ≥3symptom score threshold
    Types I–IIIeligible achalasia types

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    18+ reviewed
    age guidance
    High GERDpost-POEM risk

    Coverage Criteria for POEM

    Initial therapy (Medical necessity)

    Covered when ALL of the following are met

    POEM medical necessity criteria: A. The member has a diagnosis of primary achalasia (types I, II, or III).

    Diagnosis must be documented (achalasia subtype).

    POEM medical necessity criteria: B. POEM is proposed after the member has tried and failed conventional therapy (including pneumatic dilation) or the member is not a surgical candidate for Heller myotomy.

    Document prior therapies attempted (e.g., pneumatic dilation, botulinum toxin, or LHM) or rationale for non-surgical candidacy.

    POEM medical necessity criteria: C. Eckardt symptom score is greater than or equal to 3.Eckardt >= 3

    Record the Eckardt score in the clinical documentation.

    POEM medical necessity criteria: D. There is no history of previous open surgery of the stomach or esophagus.

    Absence of prior open stomach or esophageal surgery must be confirmed in the record.

    Age-based review

    Special considerations and age-based review

    Pediatric/young members: Members 18 or younger should be reviewed for medical necessity.

    Case-by-case review required for members ≤18 years; ensure documentation justifies POEM in younger patients.

    POEM for any other indication (other than primary achalasia types I–III) is considered experimental, investigational, and unproven.

    Peroral Endoscopic Myotomy (POEM) is considered experimental, investigational, and unproven when used for indications other than primary achalasia types I–III.

    Key Coding & Clinical Thresholds

    Eckardt Symptom Score — coverage threshold
    Eckardt score thresholdGreater than or equal to 3 (Eckardt ≥ 3)
    Scoring range0–12 total points
    Uses in policyRequired as part of medical necessity criteria for POEM coverage (must be ≥ 3)

    Provider Requirements and Workflow

    Prior Authorization

    Prior authorization required; all clinical criteria must be met

    POEM requires prior authorization and will be approved only when all policy clinical criteria are met: primary achalasia type I, II, or III; POEM proposed after attempted/failed conventional therapy or when the patient is not a surgical candidate for Heller myotomy; Eckardt symptom score ≥ 3; and no history of prior open stomach or esophageal surgery.

    Step Therapy

    Step therapy: failed conventional therapy required or not surgical candidate

    POEM is covered only after the member has tried and failed conventional therapy (including pneumatic dilation) or when the member is not a surgical candidate for laparoscopic Heller myotomy.

    • Examples of conventional therapy include pneumatic dilation (PD), botulinum toxin injection, or laparoscopic Heller myotomy (LHM).
    • Prior therapies (PD, botulinum toxin, or LHM) are not absolute contraindications to POEM per policy.

    Background

    Achalasia is a rare esophageal motility disorder characterized by degeneration of esophageal nerve cells with failure of the lower esophageal sphincter to relax, producing dysphagia and related symptoms. Treatment options include medical therapy, pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), botulinum toxin injection, and POEM. POEM is a natural-orifice endoscopic myotomy performed under general anesthesia and is used to relieve symptoms by cutting the esophageal muscle. Short-term efficacy of POEM is comparable to PD and LHM, but it carries a high risk of post-procedure gastroesophageal reflux disease (GERD), and long-term outcome data are limited. Patients should be counseled about the GERD risk prior to the procedure.

    Definitions

    Achalasia (types I, II, III) — definition and subtype summary
    DefinitionA rare esophageal disorder caused by degeneration of esophageal nerve cells leading to failure of the lower esophageal sphincter (LES) to relax, resulting in dysphagia and related complications.
    Type ICharacterized by minimal esophageal pressurization with incomplete LES relaxation and little contractile activity.
    Type IIMarked by esophageal compression/pressure build-up from failure to relax; often more severe with massive compression.
    Type IIICharacterized by spasm with sudden abnormal squeezing of the esophagus and LES; the most severe subtype and may cause chest pain and nocturnal symptoms.
    Eckardt Symptom Score — 0–12 scoring system
    PurposeA clinical grading system used to evaluate symptoms, stage, and treatment efficacy in achalasia.
    Policy Summary
    PayerCareSource Georgia
    PolicyPeroral Endoscopic Myotomy (POEM) — Coverage Criteria
    Policy CodePolicy MEDICAL POLICY STATEMENT Date Effective = Date Effective 11/01/2025
    Change TypeClinical and operational revisions (symptom threshold, age review)editorial updates
    Effective DateNov 1, 2025
    Last ReviewAug 13, 2025
    Next Review Date
    Key ActionObtain prior authorization and document diagnosis, prior therapies, Eckardt score (≥3), and absence of prior open stomach/esophageal surgery.
    SourceLink
    On This Page
    Coverage Criteria for POEMKey Coding & Clinical ThresholdsProvider Requirements and WorkflowBackgroundDefinitions
    Documentation Required

    Required clinical documentation for authorization

    Submit documentation showing the diagnosis of primary achalasia (type I, II, or III), the Eckardt symptom score (≥ 3), prior conventional therapies attempted and failed, and absence of prior open stomach or esophageal surgery; also document discussion of GERD risk and management considerations.

    • Specify prior therapies attempted (e.g., pneumatic dilation, botulinum toxin, LHM) and response.
    • Include Eckardt Symptom Score value and clinical assessment supporting score ≥ 3.
    • Document counseling about high post-POEM GERD risk and planned management.
    Denial Risk

    Coverage triggers and denial risks

    POEM may be denied if it is requested for indications other than primary achalasia types I–III or if required clinical criteria are not met (for example, no documented failed conventional therapy, Eckardt score < 3, or history of prior open stomach/esophageal surgery).

    • POEM for any other indication is considered experimental, investigational, and unproven.
    • Denials can result from missing or insufficient documentation of prior therapies, symptom score, or surgical history.
    ComponentsAttributes 0–3 points each for four symptoms: dysphagia, regurgitation, chest pain, and weight loss.
    Total score range0 to 12 points (higher scores indicate more severe symptoms).
    Peroral Endoscopic Myotomy (POEM) — procedural definition
    Procedure typeA natural orifice transluminal endoscopic myotomy performed perorally without external incisions to cut the esophageal muscle (myotomy).
    Anesthesia and approachPerformed with the patient under general anesthesia via the mouth (peroral) as an endoscopic procedure.
    Clinical contextDeveloped as an alternative to pneumatic dilation and laparoscopic Heller myotomy with comparable short-term efficacy; long-term outcome data are limited.