ModifiedKaiser PermanentePolicy N/A

Peroral endoscopic myotomy (POEM) for esophageal achalasia — Clinical Review Criteria

Clinical review criteria governing medical necessity determinations for POEM in Kaiser Foundation Health Plan of Washington members; describes indications, contraindications, required documentation, and evidence conclusions affecting coverage decisions.

Policy Summary

PayerKaiser Permanente

PolicyPeroral endoscopic myotomy (POEM) for esophageal achalasia — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeMaterial revisions and code addition

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the last 3 months of clinical notes from the requesting provider and/or consulting specialist to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added MTAC review for Per-Oral Endoscopic Myotomy (POEM) for Esophageal Achalasia.

Added new applicable CPT code to criteria.

MPC adopted new clinical criteria for Per-Oral Endoscopic Myotomy (POEM) for Esophageal Achalasia; requires 60-day notice effective 07/01/2023.

20-25%risk of GERD after POEM counseled to patients

>=50%reported rate of gastroesophageal reflux post-POEM in some series

43497CPT code listed

07/01/2023MPC effective date (requires 60-day notice)

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Coverage and Medical Necessity Criteria

Medical necessity (Non-Medicare)

Peroral endoscopic myotomy (POEM) is considered medically necessary when ALL of the following are met:

Non-Medicare POEM criteria: 1) Individual is age 18 years or older; 2) Achalasia type II covered only if patient is deemed not a surgical candidate; 3) Achalasia type III is diagnosed using esophageal manometry; 4) Patient has been counseled about a 20–25% risk of gastroesophageal reflux disease (GERD) after POEM.

From Non-Medicare section

Medical Necessity — POEM

Covered when ALL of the following are met:

General POEM coverage: POEM is considered medically necessary as an alternative to laparoscopic Heller myotomy (LHM) or pneumatic dilation (PD) for treatment of adult patients with esophageal achalasia when the applicable policy criteria are met.

See full policy criteria in Non-Medicare section and definitions for achalasia types.

POEM for any indication other than the achalasia indications specifically described in this policy is considered experimental, investigational, and unproven and therefore not covered.

Codes that have been deleted or are not in effect at the time of service may not be covered. Verify authorization and code-specific requirements by plan type using the Pre-authorization Code Check before submission.

The evidence review concluded there is insufficient evidence to determine the long-term efficacy and safety of POEM compared with laparoscopic Heller myotomy (LHM). Published studies are largely observational with short follow-up, and randomized trial data are limited; available trials and meta-analyses suggest POEM can reduce dysphagia in the short term but are associated with higher rates of gastroesophageal reflux and erosive esophagitis. Larger, long-term randomized controlled trials are needed to establish comparative safety and effectiveness.

Any procedure that does not meet the applicable policy clinical criteria listed in this document is not considered medically necessary and may be denied.

Applicable Codes

Applicable CPT CodesCPTCovered

43497

Provider Requirements, Authorization, and Operational Notes

Denial Risk

Experimental/Investigational Indications — Provider Action

Peroral endoscopic myotomy (POEM) for any indication other than the specified achalasia criteria (including but not limited to non‑achalasia esophageal motility disorders, pediatric patients <18 years, or indications not supported by esophageal manometry confirmation of achalasia type) is considered experimental, investigational, and unproven. Requests for POEM for these experimental indications will be reviewed and are not covered under the medical necessity criteria.

POEM is covered only for adult (≥18 years) achalasia meeting the policy’s clinical criteria.
Any request for POEM outside the specified achalasia indications is experimental/investigational and not medically necessary.

Background and Scope

Esophageal achalasia is a rare motility disorder characterized by absent peristalsis and impaired relaxation of the lower esophageal sphincter, leading to progressive dysphagia, regurgitation, weight loss, and increased risk of aspiration. Treatment is palliative and aims to reduce esophagogastric junction outflow resistance; options include pharmacotherapy, botulinum toxin injection, pneumatic dilation, laparoscopic Heller myotomy (often with fundoplication), and peroral endoscopic myotomy (POEM), an endoscopic submucosal tunnel myotomy technique.

Key Terms and Classifications

Achalasia types (Chicago Classification v3.0)

Type I (classic achalasia)Incomplete LES relaxation, aperistalsis, and absence of esophageal pressurization; 100% failed peristalsis.

Type IIIncomplete LES relaxation, aperistalsis, and panesophageal (pan‑esophageal) pressurization in ≥20% of swallows; simultaneous pressurization spans the entire esophagus.

Type III (spastic achalasia)Incomplete LES relaxation with premature/spastic contractions (distal latency <4.5 s) in ≥20% of swallows and DCI >450 mmHg·s·cm in ≥20% of swallows; abnormal lumen‑obliterating contractions or spasms.

POEM — Peroral endoscopic myotomy

DefinitionPeroral endoscopic myotomy (POEM) — an endoscopic submucosal tunnel myotomy procedure used to treat esophageal achalasia.

Role