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    v1.0.28
    OpenPayerPolicy UpdatesGastroenterologyIndependent Health Gastroparesis Coverage Update |…
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    CurrentIndependent HealthPolicy M20220228089

    Gastroparesis Treatments - Gastric Electrical Stimulation and Gastric Peroral Endoscopic Myotomy (G-POEM)

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    Medical necessity criteria, coverage stance, and pre-authorization requirements for gastric electrical stimulation (Enterra) and Gastric Peroral Endoscopic Myotomy (G-POEM) for treatment of gastroparesis across specified Independent Health lines of business.

    Policy Summary
    PayerIndependent Health
    PolicyGastroparesis Treatments - Gastric Electrical Stimulation and G-POEM
    Policy CodePolicy M20220228089
    Change TypeMaterial clinical change: added GLP-1 inhibitor consideration
    Effective DateApr 1, 2022
    Last ReviewApr 1, 2024
    Next Review DateN/A
    Key ActionObtain pre-authorization and document objective delayed gastric emptying by standard scintigraphic imaging of solid food before approving G-POEM or gastric electrical stimulation.
    SourceLink
    POLICY UPDATE CHANGES

    Note: Members receiving GLP-1 Inhibitors should consider this treatment as the gastroparesis etiology prior to a surgical procedure.

    Policy revised and reviewed multiple times with entries indicating revisions on 1/1/2024 and 4/1/2024.

    Pre-auth

    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.

    authorization status
    HDE (Enterra)regulatory status
    >60% @2h / >10% @4hdiagnostic threshold
    ≥6 monthssymptom duration
    MediSource & morelines of business

    Coverage Criteria

    Gastric Electrical Stimulation - Initial therapy

    Gastric electrical stimulation is considered medically necessary when ALL of the following are met:

    GES medical necessity criteria: 1) Chronic intractable nausea and vomiting secondary to severe gastroparesis of diabetic or idiopathic etiology; 2) Individual is refractory, intolerant, or has contraindications to prokinetic and antiemetic medications; 3) Delayed gastric emptying documented by standard scintigraphic imaging of solid food.

    GES (Enterra) has FDA Humanitarian Device Exemption approval for refractory diabetic and idiopathic gastroparesis.

    G-POEM - Initial therapy

    G-POEM is considered medically necessary when ALL of the following are met:

    G-POEM initial criteria: 1) Diagnosis of gastroparesis confirmed by a gastric emptying study (GES), where abnormal GES is defined in this policy as gastric retention >60% at 2 hours and/or >10% at 4 hours after meal ingestion; 2) Symptom duration >6 months; 3) Inadequate response to conservative treatment including dietary modification and a trial of at least one prokinetic agent (domperidone, metoclopramide, or erythromycin).

    American Gastroenterological Association guidance referenced; policy specifies the above GES thresholds.

    Not Medically Necessary / Experimental

    Services considered not medically necessary or experimental:

    Not medically necessary / Experimental: 1) Gastric electrical stimulation for all indications other than refractory diabetic or idiopathic gastroparesis (including obesity); 2) G-POEM for treatment of congenital hypertrophic pyloric stenosis and all other indications not specified as medically necessary (considered experimental).

    Gastric electrical stimulation is not medically necessary for indications other than chronic intractable nausea and vomiting secondary to severe diabetic or idiopathic gastroparesis. This includes, but is not limited to, use of gastric electrical stimulation for the treatment of obesity.

    G-POEM is considered experimental and not medically necessary when used for indications that are not specified as medically necessary in this policy. Examples include treatment of congenital hypertrophic pyloric stenosis and any other indications outside the criteria listed for G-POEM. Providers should follow the policy’s medical necessity requirements (confirmed abnormal GES, symptom duration, and prior conservative therapy) before considering G-POEM.

    Coding and Regulatory Status

    Regulatory / Device Codemixed
    H990014 (HDE)Gastric Electrical Stimulation (GES) System Humanitarian Device Exemption reference
    GES abnormal retention thresholds (policy-defined)
    Policy-defined abnormal GES retentionGastric retention >60% at 2 hours and/or >10% at 4 hours after meal ingestion (abnormal per this policy)
    AGA preferred threshold (not policy)American Gastroenterological Association guidance prefers retention >20% at 4 hours for delayed emptying
    Use contextThese thresholds are used to confirm diagnosis by gastric emptying study (GES) before G-POEM is considered medically necessary

    Provider Actions and Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for both Gastric Electrical Stimulation (GES) and G-POEM prior to scheduling the procedure. Submit pre-authorization requests with supporting clinical documentation (see Documentation requirements callout).

    • Affected services: GES and G-POEM
    • Pre-authorization required for Commercial, Self-Funded and Medicare Advantage members
    • Ensure authorization is obtained before the procedure date
    Step Therapy

    Conservative Therapy Prerequisite for G-POEM

    G-POEM is covered only after a trial of conservative therapy. Members must have had inadequate response to dietary modification and a trial of at least one prokinetic agent (such as domperidone, metoclopramide, or erythromycin). Symptom duration must be greater than 6 months prior to consideration of G-POEM.

    • Required conservative treatments: dietary modification AND trial of at least one prokinetic agent (domperidone, metoclopramide, or erythromycin)

    Definitions

    Gastric electrical stimulation (Enterra)
    Device name and manufacturerEnterra Therapy gastric electrical stimulation system (Medtronic Inc.)
    Device componentsSystem consists of a pair of leads, an implanted pulse generator (IPG), and a programming system
    Mechanism of actionDelivers electrical impulses via electrodes attached to the stomach to stimulate coordinated contractions and improve gastric emptying
    Regulatory statusHas FDA Humanitarian Device Exemption approval for treatment of refractory diabetic and idiopathic gastroparesis
    G-POEM — definition and procedure
    DefinitionG-POEM (Gastric Peroral Endoscopic Myotomy) is an endoscopic pyloromyotomy — an endoscopic equivalent of surgical pyloroplasty that myotomizes the pylorus

    Background

    Gastroparesis is a chronic disorder characterized by delayed gastric emptying in the absence of mechanical obstruction, commonly presenting with nausea, vomiting, early satiety, bloating, and potential malnutrition. Initial management emphasizes conservative measures such as dietary modification, glycemic optimization, hydration, and prokinetic or antiemetic medications; patients with severe, refractory symptoms may be considered for advanced interventions including gastric electrical stimulation (Enterra system) or pyloric-directed procedures such as G-POEM when policy criteria are met. The policy also notes that G-POEM involves endoscopic pyloromyotomy via a submucosal tunnel and cites guidance favoring objective confirmation of delayed gastric emptying prior to intervention.

    Policy Summary
    PayerIndependent Health
    PolicyGastroparesis Treatments - Gastric Electrical Stimulation and G-POEM
    Policy CodePolicy M20220228089
    Change TypeMaterial clinical change: added GLP-1 inhibitor consideration
    Effective DateApr 1, 2022
    Last ReviewApr 1, 2024
    Next Review DateN/A
    Key ActionObtain pre-authorization and document objective delayed gastric emptying by standard scintigraphic imaging of solid food before approving G-POEM or gastric electrical stimulation.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Regulatory StatusProvider Actions and RequirementsDefinitionsBackground
  1. Symptom duration > 6 months required
  2. G-POEM is not indicated as first-line therapy; failure of other interventions (e.g., GES, pyloric stenting, botulinum toxin) is not required but may be considered
    3. Documentation Required

    Required Clinical Documentation

    Documented objective evidence of delayed gastric emptying and thorough symptom documentation are required with the authorization request. Include results of a standardized gastric emptying study (GES) and clinical notes describing severity and duration of symptoms and prior therapies tried.

    • Required objective testing: standardized solid‑meal gastric emptying scintigraphy (GES) showing abnormal retention (for G-POEM policy: >60% at 2 hours and/or >10% at 4 hours per policy criteria; note AGA prefers >20% at 4 hours)
    • Clinical documentation: symptom history with duration (>6 months for G-POEM), predominant symptoms (e.g., nausea, vomiting), impact on nutrition/weight, and response/intolerance to medications
    • Treatment history: records of dietary modification and trials of prokinetic and antiemetic medications, including agents tried and reasons for discontinuation (intolerance, contraindication, or inadequate response)
    • For GES: documentation that the individual is refractory, intolerant, or has contraindications to prokinetic and antiemetic medications when seeking GES therapy
    Denial Risk

    Not Medically Necessary Indications / Denial Risk

    G-POEM and GES are not medically necessary for indications outside those specified in the policy. Procedures performed for other indications (including obesity and congenital hypertrophic pyloric stenosis for G-POEM) are considered experimental or not medically necessary and are at high risk for denial.

    • Not covered / denial-risk indications: GES for obesity; G-POEM for congenital hypertrophic pyloric stenosis and other non-covered indications
    • Ensure documentation supports gastroparesis etiology (consider GLP‑1 inhibitor use as potential cause) and meets policy clinical thresholds to avoid denial
    Procedural techniqueProcedure typically creates a submucosal tunnel ~5 cm proximal to the pylorus along the greater curvature or anterior gastric wall, then performs a short (~2 cm) antral myotomy plus pyloromyotomy via the tunnel
    IndicationPerformed for severe, refractory gastroparesis after confirming no mechanical gastric outlet obstruction and objective delayed gastric emptying
    Gastroparesis — definition and common symptoms
    Core definitionGastroparesis is delayed gastric emptying in the absence of mechanical obstruction
    Most common symptomsNausea and protracted vomiting
    Other frequent symptomsEarly satiety, abdominal bloating/distension, and epigastric pain; severe cases may have malnutrition