Modifiedpriority healthPolicy NO. 91616

PERORAL ENDOSCOPIC MYOTOMY (POEM)

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Defines medical necessity criteria and limitations for POEM, including Z-POEM, for treatment of esophageal achalasia, Zenker's diverticulum, and select non-achalasia spastic esophageal motility disorders; applies to Priority Health members and providers.

Policy Summary

Payerpriority health

PolicyPERORAL ENDOSCOPIC MYOTOMY (POEM)

Policy CodePolicy NO. 91616

Change TypeExpanded indicationsupdated exclusions and organization

Effective DateJun 1, 2026

Last ReviewMay 13, 2026

Next Review DateMay 13, 2026

Key ActionSubmit prior authorization demonstrating medical necessity with diagnostic documentation (HRM, supportive studies) and prior therapy history.

SourceLink

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Modifiedpriority healthPolicy NO. 91616

PERORAL ENDOSCOPIC MYOTOMY (POEM)

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Sign up for priority health Policy NO. 91616 alerts

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Policy Summary

Payerpriority health

PolicyPERORAL ENDOSCOPIC MYOTOMY (POEM)

Policy CodePolicy NO. 91616

Change TypeExpanded indicationsupdated exclusions and organization

Effective DateJun 1, 2026

Last ReviewMay 13, 2026

Next Review DateMay 13, 2026

Key ActionSubmit prior authorization demonstrating medical necessity with diagnostic documentation (HRM, supportive studies) and prior therapy history.

SourceLink

Coverage and Medical Necessity Criteria

Esophageal Achalasia

Covered when ALL of the following are met:

Achalasia diagnosis and indications: 1) Confirmed diagnosis of esophageal achalasia demonstrated by: a) esophageal high-resolution manometry demonstrating findings consistent with achalasia per the Chicago Classification; and b) supporting diagnostic evaluation as clinically appropriate (e.g., timed barium esophagram and/or upper endoscopy). 2) One of the following clinical indications: a) primary esophageal achalasia (Type I, II, or III); or b) failure of, contraindication to, or intolerance of prior achalasia treatment, including but not limited to Heller myotomy, pneumatic dilation, or botulinum toxin injection.

Zenker's Diverticulum (Z-POEM)

Covered when ANY of the following are met:

Z-POEM indications: 1) The member has symptomatic Zenker's diverticulum, including but not limited to dysphagia, regurgitation, weight loss, cough, aspiration, or hoarseness; 2) Recurrent or persistent symptoms following a prior endoscopic or surgical septotomy; 3) Anatomic features favoring a complete cricopharyngeal myotomy where conventional septotomy may be incomplete or technically limited; 4) Moderate-to-large Zenker's diverticula where durable symptom relief may require complete myotomy; 5) The member is a poor candidate for rigid stapled diverticulectomy (e.g., limited neck extension, restricted oral opening, short diverticulum length, or significant medical comorbidities).

Z-POEM shown in systematic reviews and cohorts to provide high technical success and clinically meaningful symptom improvement; consider when indicated.

Non-Achalasia Spastic Motility Disorders

Considered medically necessary on an individual case-by-case basis when ALL of the following are met:

Non-achalasia spastic disorders: 1) Completion of a comprehensive diagnostic evaluation with symptom correlation including: a) confirmatory physiologic/functional esophageal testing (e.g., impedance planimetry [FLIP], timed barium esophagram, and pH study); and b) exclusion of alternative or contributing causes (e.g., obesity, obstructive hiatal hernia, gastroesophageal reflux disease, external compression, submucosal masses, medications such as opioids). 2) Failure of first-line, less invasive therapies including: a) medical therapy (e.g., antispasmodic agents, antihypertensive agents, antidepressants); b) botulinum toxin injections; and c) endoscopic dilation.

POEM for these indications is individualized and requires documented prior therapies and detailed physiologic workup.

General coverage criteria for POEM/Z-POEM

Covered when ALL of the following are met (condition-specific criteria summarized in policy):

General: POEM or Z-POEM is considered when there is documentation of a symptomatic esophageal motility disorder (e.g., achalasia, select non-achalasia spastic disorders, or symptomatic Zenker's diverticulum) and medical necessity is demonstrated in the prior authorization submission.

Supported by guideline citations and evidence summaries; see condition-specific sections for detailed diagnostic, prior therapy, and anatomic criteria.

POEM is not considered medically necessary when any of the following apply: (1) esophageal malignancy or suspicion for pseudoachalasia due to malignancy; (2) untreated or unstable bleeding disorder, including clinically significant coagulopathy; (3) inability to tolerate general anesthesia; or (4) severe medical comorbidities (for example, severe pulmonary disease) that preclude endoscopic or surgical intervention.

Exclusion criteria have been updated to align with recent society guideline recommendations; the policy explicitly notes these updated exclusions and that criteria structure has been reorganized for clarity across achalasia, Zenker's diverticulum, and select non-achalasia spastic disorders.

Peroral endoscopic myotomy (POEM) is considered experimental and not medically necessary for all indications that are not explicitly supported by this policy due to insufficient evidence of efficacy.

Treatments characterized as experimental, investigational, or unproven may be excluded from coverage unless an exception is approved. Requests for individual case review or exception require prior plan approval and will be adjudicated by a Priority Health medical director or clinical pharmacist. Exceptions may be considered for terminal illness or chronic, life‑threatening, severely disabling conditions producing serious clinical deterioration.

Coding, Diagnosis, and Billing

Referenced LCDsmixed

L38747

Palmetto GBA LCD - Peroral Endoscopic Myotomy (POEM) referenced

ICD-10 Codes that may support medical necessityICD-10

K22.0	Achalasia of cardia
K22.4	Dyskinesia of esophagus
K22.5	Diverticulum of esophagus, acquired
K22.89	Other specified diseases of esophagus

CPT/HCPCS CodesCPT

74246	Radiologic examination, upper gastrointestinal tract; double-contrast study (including scout and delayed images when performed)
91010	Esophageal motility study with interpretation and report
91013	Esophageal motility study with stimulation or perfusion
32665	Thoracoscopy with esophagomyotomy (Heller type)
43279	Laparoscopy, esophagomyotomy (Heller type), with fundoplasty when performed
43330	Esophagomyotomy (Heller type); abdominal approach
43497	Lower esophageal myotomy, transoral (e.g., peroral endoscopic myotomy [POEM])
43499	Unlisted procedure, esophagus (used for Z-POEM)

POEM / Z-POEM coding and billing

Primary CPT for POEM43497 — Lower esophageal myotomy, transoral (peroral endoscopic myotomy [POEM]).

Unlisted procedure for Z-POEM43499 — Unlisted procedure, esophagus; document use of 43499 when billing Z‑POEM as an unlisted esophageal procedure.

Billing guidanceWhen Z-POEM is performed and no specific CPT exists, use 43499 with detailed operative report and consider prior authorization documentation referencing clinical indication and technique.

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required when POEM, Z-POEM, or similar endoscopic myotomy procedures are requested. Providers must submit a prior authorization request demonstrating that the procedure meets medical necessity criteria, including diagnosis confirmation, relevant symptoms, prior treatments, and required diagnostic documentation. See Priority Health Provider Manual for submission process and forms.

Prior authorization required for POEM and Z-POEM when indicated
Provider must document medical necessity and submit supporting records with the request

Documentation Required

Required Diagnostic Documentation for Achalasia

For esophageal achalasia, providers must include objective diagnostic documentation with the prior authorization request: high-resolution esophageal manometry (HRM) with findings consistent with achalasia interpreted using the Chicago Classification (CCv4.0) and specification of achalasia subtype (Type I, II, or III). Supporting studies should be submitted when available, such as a timed barium esophagram and upper endoscopy (to exclude pseudoachalasia/malignancy). Include procedure and diagnosis codes where applicable.

Clinical Background and Rationale

Esophageal achalasia is a primary esophageal motility disorder characterized by impaired esophagogastric junction relaxation and absent or disordered peristalsis, producing symptoms such as dysphagia, regurgitation, chest pain, weight loss, and increased aspiration risk. Diagnosis requires physiologic testing with high‑resolution manometry interpreted per the Chicago Classification (CCv4.0), with supportive studies as clinically appropriate (for example, timed barium esophagram and upper endoscopy). Peroral endoscopic myotomy (POEM) is a transoral submucosal tunneling myotomy performed under general anesthesia and is an established endoscopic treatment option as an alternative to surgical myotomy for appropriately selected patients with achalasia.

Definitions and Clinical Classifications

Achalasia subtypes (Chicago Classification v4.0)

Type I (Classic) AchalasiaAbnormal median IRP with absent contractility — defined as 100% failed peristalsis.

Type II AchalasiaAbnormal median IRP with absent contractility (100% failed peristalsis) plus panesophageal pressurization in ≥20% of swallows.

Type III (Spastic) AchalasiaAbnormal median IRP with evidence of spasm — ≥20% swallows with premature contractions and absence of normal peristalsis.

Z-POEM: submucosal tunneling technique and purpose

DefinitionZ-POEM is a third-space submucosal tunneling technique adapted from esophageal POEM to perform controlled cricopharyngeal myotomy for Zenker's diverticulum.

PurposeAllows complete division of the cricopharyngeal muscle to relieve functional outflow obstruction and improve symptoms such as dysphagia and aspiration.

Policy Revision History

2026-06-01Effective dateLatest

Policy modified to explicitly expand covered indications to include Zenker's diverticulum (Z-POEM) and select non-achalasia spastic motility disorders, and to add medical necessity criteria for Z-POEM; adopts a new policy template standardization.

2026-05-13Review

Policy underwent review preceding the effective date; last review completed (see policy record for details).

2026-05-13Administrative change