Modifiedselect_healthPolicy CCP.1199

Peroral endoscopic myotomy (POEM)

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This policy governs coverage and medical necessity criteria for peroral endoscopic myotomy (including esophageal POEM and gastric POEM) for treatment of achalasia and medically refractory gastroparesis in adults, and describes investigational indications and contraindications; it applies to Select Health of South Carolina members and providers making coverage determinations.

Policy Summary

Payerselect_health

PolicyPeroral endoscopic myotomy (POEM)

Policy CodePolicy CCP.1199

Change TypeCoverage indications revised (evidence/guideline update)

Effective DateJan 1, 2025

Last ReviewNov 1, 2025

Next Review DateMar 1, 2027

Key ActionObtain prior authorization demonstrating the required diagnostic workup and documentation of prior therapy failures (for gastric POEM) before scheduling POEM.

SourceLink

POLICY UPDATE CHANGES

Coverage indications for peroral endoscopic myotomy were revised to incorporate updated evidence-based guidance emphasizing a comprehensive diagnostic evaluation, standardized gastric emptying testing protocols, and symptom duration thresholds.

Coverage indications revised to incorporate updated evidence-based guidance emphasizing a comprehensive diagnostic evaluation, standardized gastric emptying testing protocols, and symptom duration thresholds.

A new section on non-achalasia spastic disorders was added to the guidelines.

91.3%POEM clinical success (2y)

≥20% @4hG-POEM threshold

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Modifiedselect_healthPolicy CCP.1199

Peroral endoscopic myotomy (POEM)

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Sign up for select_health Policy CCP.1199 alerts

Get alerted when Policy CCP.1199 changes without checking for updates manually.

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Policy Summary

Payerselect_health

PolicyPeroral endoscopic myotomy (POEM)

Policy CodePolicy CCP.1199

Change TypeCoverage indications revised (evidence/guideline update)

Effective DateJan 1, 2025

Last ReviewNov 1, 2025

Next Review DateMar 1, 2027

Key ActionObtain prior authorization demonstrating the required diagnostic workup and documentation of prior therapy failures (for gastric POEM) before scheduling POEM.

SourceLink

POLICY UPDATE CHANGES

A new section on non-achalasia spastic disorders was added to the guidelines.

91.3%POEM clinical success (2y)

≥20% @4hG-POEM threshold

≥18 yrsAge requirement

ListedContraindication categories

MultipleUpdate history

Coverage and Medical Necessity Criteria

Esophageal achalasia (POEM)

Covered when ALL of the following are met

Achalasia POEM coverage criteria: 1) A comprehensive diagnostic workup has been completed, including upper endoscopy, high-resolution manometry, and timed barium esophagram (functional luminal impedance planimetry may be used as an adjunct if diagnosis is equivocal); 2) Member is treatment-naïve or has recurrent/persistent achalasia following pneumatic dilation, laparoscopic Heller myotomy, or prior POEM; 3) Diagnosis of esophageal achalasia type I, II, or III based on high-resolution manometry; 4) Shared decision-making addressing increased post-POEM gastroesophageal reflux risk with a plan for acid suppression and objective reflux surveillance as indicated.

Gastric POEM (G-POEM)

Covered when ALL of the following are met

Gastric POEM coverage criteria: 1) Member is age 18 years or older; 2) Esophagogastroduodenoscopy confirms absence of mechanical gastric outlet obstruction; 3) A standardized four-hour solid‑phase gastric emptying scan demonstrates delayed gastric emptying (policy uses ≥20% retention at 4 hours on Eggbeaters meal for candidacy); 4) Moderate-to-severe symptoms present for at least 6–12 months (typically nausea, vomiting, postprandial fullness); 5) Medically refractory disease defined by failure of at least two medical treatments, including ≥3 months of a prokinetic agent and at least one antiemetic, after medication reconciliation and glycemic optimization when applicable.

Investigational / Not Medically Necessary

Not medically necessary / investigational indications: POEM is investigational and not medically necessary for treatment of esophageal diverticula and for gastroparesis in pediatric patients (<18 years).

References: Mandavdhare 2021; Staller 2025

Covered Indications (summary)

Policy coverage indications were revised using updated evidence and guideline recommendations.

Covered Indications summary: POEM is supported for esophageal achalasia, esophageal diverticula, and gastric POEM for medically refractory gastroparesis when patients meet comprehensive diagnostic evaluation criteria, standardized gastric emptying testing (for gastroparesis), and symptom duration and prior-treatment failure thresholds per recent 2024–2025 society guidance.

Derived from policy revision statement and referenced guidelines/meta-analyses.

Contraindications to any peroral endoscopic myotomy procedures include uncorrected coagulopathy, liver cirrhosis, pregnancy at the time of treatment, severe erosive esophagitis, presence of a cardiac pacemaker, severe pulmonary disease, and being not a candidate for endoscopic examination or anesthesia.

Additional contraindications specific to esophageal POEM include secondary achalasia or other organic causes of dysphagia (for example, esophageal varices, Barrett's esophagus, esophageal stricture, malignant or premalignant lesions, or an extremely dilated esophageal body > 6 cm), and prior therapies that may compromise esophageal mucosal or submucosal integrity (recent esophageal surgery, radiation, endoscopic mucosal resection, or radiofrequency ablation).

For gastric POEM, additional contraindications include an absent pylorus, prior gastrointestinal surgery that alters the stomach, and postinfectious gastroparesis.

The portion of the document cited here does not list any additional explicit exclusion conditions beyond those enumerated elsewhere in the policy update history and limitations sections.

Peroral endoscopic myotomy is designated investigational / not medically necessary for certain indications in this policy. Specifically, the procedure is considered not medically necessary for treatment of esophageal diverticula and for gastroparesis in pediatric populations (< 18 years).

The provided document portion does not include a separate, explicit list labeled 'not medically necessary' beyond the investigational indications already stated; updates and revisions are documented in the policy update history without additional named exclusions in this section.

Coding and Diagnostic Thresholds

Covered CPT CodesCPT

No codes listed

Codes referencedmixed

No codes listed

Gastric emptying retention at 4 hours

Gastric emptying retention thresholdPolicy requires ≥20% retention at 4 hours on a standardized four-hour Eggbeaters solid‑phase gastric emptying scan for G‑POEM candidacy.

Guideline diagnostic cutoffsAGA guidance notes diagnostic delayed emptying as >10% retention at 4 hours with Eggbeaters or >25% with a real egg meal (policy uses 20% as a cohort/predictive threshold).

Test specificationStandardized four‑hour Eggbeaters meal solid‑phase gastric emptying scintigraphy is the required test method referenced in the policy.

None specified

SpecificationNone specified in policy text for this item.

Related note

Authorization, Documentation, and Operational Requirements

Prior Authorization

Obtain prior authorization showing diagnostic criteria and prior therapy failures

Prior authorization is required and must document that the member meets the policy’s diagnostic criteria and, for gastric POEM, prior therapy failures before approval for POEM.

For achalasia: documented completion of a comprehensive diagnostic workup including upper endoscopy, high-resolution manometry, and timed barium esophagram (FLIP may be adjunctive).
For gastric POEM: esophagogastroduodenoscopy showing no mechanical outlet obstruction and a standardized 4‑hour Eggbeaters gastric emptying scan with ≥20% retention at 4 hours, plus failure of ≥2 medical treatments including ≥3 months of a prokinetic and ≥1 antiemetic.

Prior Authorization

Document diagnostic evaluation per updated guidance when requesting authorization

Obtain prior authorization that explicitly documents the diagnostic evaluation and testing per the 2025 guidance prior to scheduling POEM.

Authorization should reference completion of the comprehensive diagnostic evaluation and standardized testing required by updated guidance.

Clinical Background and Scope

Achalasia is an esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter and loss of peristalsis; diagnosis relies primarily on high-resolution manometry with classification by the Chicago system and supportive testing such as upper endoscopy and timed barium esophagram (with FLIP considered adjunctive when diagnosis is equivocal).

Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic myotomy performed via submucosal tunneling to divide the muscular layer of the esophagus (or stomach for G-POEM) and is used to relieve outflow obstruction in achalasia; treatment decisions depend on comprehensive diagnostic evaluation and shared decision-making about reflux risk and follow-up surveillance.

Clinical Definitions and Scoring Systems

Eckardt score

Score range0–12 total points, higher scores indicate more severe symptoms.

ComponentsFour symptom domains scored 0–3 each: dysphagia, regurgitation, chest pain, and weight loss.

Clinical stagingScores: 0–1 = stage 0; 2–3 = stage I; 4–6 = stage II; >6 = stage III.

Chicago Classification (HRM types I–III)

Classification typesChicago Classification (HRM): Type I = 100% failed peristalsis; Type II = 100% failed peristalsis with panesophageal pressurization in ≥20% of swallows; Type III = absent normal peristalsis with premature/spastic contractions in ≥20% of swallows.

Diagnostic methodDefined by high‑resolution esophageal manometry (HRM) per Chicago Classification criteria.

Policy Summary

Payerselect_health

PolicyPeroral endoscopic myotomy (POEM)

Policy CodePolicy CCP.1199

Change TypeCoverage indications revised (evidence/guideline update)

Effective DateJan 1, 2025

Last ReviewNov 1, 2025

Next Review DateMar 1, 2027

Key ActionObtain prior authorization demonstrating the required diagnostic workup and documentation of prior therapy failures (for gastric POEM) before scheduling POEM.

SourceLink

On This Page

No additional numeric thresholds or alternative test meals are provided in the cited policy portion.

ImplicationIf a threshold is needed, refer to the standardized gastric emptying scan protocol (Eggbeaters) noted elsewhere in the policy.

Providers should not assume coverage without prior authorization documenting these evaluations.

Step Therapy

Document trials of less invasive alternatives (step therapy considerations)

Consider and document less invasive alternative therapies and sequencing prior to or during shared decision-making for POEM candidates.

Alternatives include endoscopically-guided pneumatic dilation, botulinum toxin injection, oral pharmacologic therapy, and surgical options (open/laparoscopic esophagomyotomy with or without fundoplication).
For gastroparesis, consider pyloric interventions (pyloric stenting, surgical pyloroplasty) and other non-POEM options as applicable.

Documentation Required

Include all required diagnostic studies and clinical details with the request

Ensure the authorization request and medical record include all required diagnostic studies and clinical details listed in the policy; missing documentation may delay or prevent coverage.

Required studies for achalasia: upper endoscopy, high-resolution manometry, timed barium esophagram (FLIP may be adjunctive).
Required studies for gastroparesis: standardized 4‑hour solid‑phase gastric emptying study using Eggbeaters with percent retention at 4 hours, symptom duration, and history of failed medical therapies.
Include age (≥18 years for G‑POEM), symptom duration (6–12 months), and details of prior treatments tried.

Documentation Required

Document required clinical testing and symptom duration thresholds

Provide comprehensive diagnostic documentation in the medical record demonstrating evaluation per the 2025 guidance, including standardized gastric emptying testing and symptom duration thresholds.

For gastroparesis: record the 4‑hour Eggbeaters gastric emptying percent retention (policy threshold ≥20% at 4 hours) and note symptom duration (typically 6–12 months).
For achalasia: document upper endoscopy, high‑resolution manometry confirming achalasia subtype, and timed barium esophagram results.

Denial Risk

Incomplete diagnostic workup or missing prior‑therapy documentation may trigger denial

Failure to complete the required diagnostic workup or to document age, symptom duration, or prior-treatment failures may result in denial of POEM.

Denial triggers include missing upper endoscopy, high-resolution manometry, timed barium esophagram for achalasia, or absence of a standardized 4‑hour gastric emptying scan for gastroparesis.
For G‑POEM, lacking documentation of failure of ≥2 medical therapies (including ≥3 months of a prokinetic and ≥1 antiemetic) or age <18 years can trigger denial.

Documentation Required

Documentation gaps tied to updated coverage indications increase denial risk

Revised coverage indications emphasize comprehensive diagnostic evaluation, standardized gastric emptying testing, and symptom duration; failure to document these elements in the record is specifically linked to denial risk.

Policy revisions incorporate 2024–2025 society guidance and require documentation of standardized testing and symptom duration thresholds to support medical necessity.
Lack of documented standardized 4‑hour gastric emptying results or absence of documented symptom duration/prior therapy failure increases risk of coverage denial.

Use in policyManometric classification (Types I–III) required to establish achalasia diagnosis for POEM coverage determinants.

Peroral endoscopic myotomy (POEM)

DefinitionPeroral endoscopic myotomy (POEM) is an endoscopic procedure that creates a submucosal tunnel and performs a myotomy of the muscular layer across the esophagogastric junction (or pylorus for gastric POEM) to treat achalasia, esophageal diverticula, or refractory gastroparesis.

Procedural scopeEsophageal POEM targets the lower esophageal sphincter for achalasia and may be applied to esophageal diverticula; gastric POEM (G‑POEM) targets the pylorus for refractory gastroparesis.

Technique overviewInvolves mucosal incision, creation of a submucosal tunnel crossing the junction (or to the pylorus), myotomy, and mucosal closure; developed as a minimally invasive endoscopic myotomy technique.

Indications in policySupported for esophageal achalasia, esophageal diverticula, and select adult G‑POEM for refractory gastroparesis when diagnostic and symptom criteria are met.