CurrentPremera BluecrossPolicy N/A

2.01.91 Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia and Gastroparesis

Policy Summary

PayerPremera Bluecross

Policy2.01.91 Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia and Gastroparesis

Policy CodePolicy N/A

Change TypeTitle/coding updatesinvestigational statement added for G-POEM

Effective Date

Next Review Date

Key ActionReport CPT 43497 for POEM and CPT 43499 (unlisted procedure, esophagus) for G-POEM; document procedure specifics when using unlisted code.

SourceLink

POLICY UPDATE CHANGES

Policy title changed 02/01/24 to add gastroparesis: 'Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia and Gastroparesis'.

01/01/22 coding update: Added CPT code 43497 and removed CPT code 43499.

02/01/20 policy statement clarified for pediatric and adult esophageal achalasia; intent unchanged.

02/01/23 wording changed from 'patient' to 'individual' throughout the policy for standardization.

02/01/26 annual review updated literature through September 23, 2025; policy statements unchanged.

1Coverage Position (Investigational)

2Primary CPT codes listed

4Recent Guideline Sources Cited

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Coverage Summary & Position

Defines Premera Bluecross policy coverage position and evidence summary for peroral endoscopic myotomy (POEM) for esophageal achalasia and gastric POEM (G-POEM) for gastroparesis, including coding, related guidelines, evidence review, and recommendations from specialty societies. This is Part 1 of 2 of the policy document. Service considered investigational: Peroral endoscopic myotomy (POEM) is considered investigational as a treatment for pediatric and adult esophageal achalasia. Coverage stance: not_covered_cosmetic (investigational). Last review date: 2026-01-12.

Policy metadata

Policy TitlePeroral Endoscopic Myotomy for Treatment of Esophageal Achalasia and Gastroparesis

Policy Number

StatusCURRENT (investigational coverage position)

Last review date2026-01-12

Conditions addressedachalasia, gastroparesis

Primary CPT codes referenced43497, 43499

Policy Coverage Criteria (Investigational Statements)

Policy Coverage Criteria

Service considered investigational:

POEM for esophageal achalasia: Peroral endoscopic myotomy (POEM) is considered investigational as a treatment for pediatric and adult esophageal achalasia.
POEM is a transoral endoscopic myotomy of the lower esophageal sphincter.
G-POEM for gastroparesis: Gastric peroral endoscopic myotomy (G-POEM) is considered investigational as a treatment for gastroparesis.
G-POEM myotomizes the pylorus; use CPT 43499 (unlisted procedure, esophagus) per policy.

Supporting context: Policy and evidence summaries note that evidence (RCTs, systematic reviews, observational studies) is insufficient to determine improvement in net health outcome for POEM in adults and pediatrics and for G-POEM in gastroparesis.

CPT / HCPCS Codes

Listed CPT codesCPT

43497	Lower esophageal myotomy, transoral (i.e., peroral endoscopic myotomy [POEM])
43499	Unlisted procedure, esophagus (use for G-POEM)

Referenced CPT codesCPT

43497	CPT code added in 01/01/22; specific description not provided in this part
43499	HCPCS/CPT code 43499 removed then added back to policy; specific description not provided in this part

Billing, Documentation & Provider Requirements

Documentation Required

Use of CPT 43497 and 43499

Report CPT 43497 for POEM (lower esophageal myotomy, transoral) and use CPT 43499 (unlisted procedure, esophagus) for G-POEM. When billing with the unlisted code 43499, document the specific procedure details (that it is a pyloromyotomy/G-POEM), operative findings, and any other information necessary to support use of an unlisted code and allow appropriate adjudication.

43497
43499

Documentation Required

Consult member benefit booklet / member services

Providers must consult the member benefit booklet or contact a member service representative to determine coverage and any benefit limitations that apply to a specific member before proceeding with billing or scheduling.

Clinical Background & Evidence Summary

POEM is a novel endoscopic procedure using a transoral approach to myotomize the lower esophageal sphincter for achalasia; G-POEM targets the pylorus for gastroparesis. Evidence includes systematic reviews, randomized trials, and observational studies. For achalasia, RCTs and comparative studies found similar or greater treatment success than pneumatic dilation or laparoscopic Heller myotomy but higher reflux rates; overall evidence was judged insufficient to determine improvement in net health outcome. For gastroparesis, meta-analyses, RCTs, and nonrandomized studies reported clinical success measures but the evidence was also deemed insufficient to determine improvement in net health outcome.

Evidence summary

RCTs for achalasiaFour randomized controlled trials and multiple observational studies; RCTs showed similar or greater treatment success vs pneumatic dilation or LHM but higher reflux rates; evidence insufficient to determine improvement in net health outcome.

G-POEM evidenceTwo meta-analyses, two randomized controlled trials, and nonrandomized studies reporting clinical success (GCSI improvements, 61–75%); evidence insufficient to determine improvement in net health outcome.

Recent randomized and guideline evidenceReferences include randomized trials and multiple society guidelines through 2024–2025 (ACG, ASGE, SAGES, AGA) informing recommendations and updates.

Medicare Coverage

Medicare determinations: No national coverage determination (NCD).

Policy Revision Timeline

02/01/24policy_revision

Policy title changed to add gastroparesis: 'Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia and Gastroparesis'; new investigational policy statement added for use in gastroparesis; HCPCS/CPT code 43499 added back to policy.

01/01/22coding_update

Coding update: CPT code 43497 added and CPT/HCPCS code 43499 removed from the policy.

02/01/23wording_standardization