CurrentUnitedHealthcarePolicy CS079IN.04

Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Indiana Only) – Community Plan Medical Policy

State-specific (Indiana) medical policy defining medical necessity and investigational/not medically necessary positions for minimally invasive procedures for GERD, achalasia, diffuse esophageal spasm, and gastroparesis including POEM, G-POEM, gastric electrical stimulation (GES), pyloroplasty, and various endoluminal/endoscopic therapies. Includes applicable CPT/HCPCS codes and references to InterQual criteria where indicated.

Policy Summary

PayerUnitedHealthcare

PolicyMinimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Indiana Only) – Community Plan Medical Policy

Policy CodePolicy CS079IN.04

Change TypeNew Medical Policy

Effective DateApr 1, 2026

Next Review Date

Key ActionEnsure the patient medical record contains documentation fully supporting medical necessity, including relevant history, exam, and diagnostic test results, and make documentation available upon request.

SourceLink

POLICY UPDATE CHANGES

New Medical Policy

POEM CoveredPOEM: Covered for Achalasia & Diffuse Esophageal Spasm

G-POEM N/MNG-POEM: Not medically necessary for Gastroparesis

GES CoveredGES: Covered for refractory gastroparesis (diabetic/idiopathic)

GERD Therapies N/MN

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LINX and many endoscopic GERD therapies: Not medically necessary/investigational

AGA GuidanceAGA guidance: POEM preferred for type III achalasia

Evidence MixedOverall evidence strength: mixed/limited

Coverage Summary

This Indiana-specific medical policy (Policy Number: CS079IN.04) is effective April 1, 2026 and addresses minimally invasive procedures for upper gastrointestinal diseases including GERD, achalasia, diffuse esophageal spasm, and gastroparesis. The policy stance is mixed: some procedures are designated as medically necessary in specified indications while many endoscopic or implant approaches are considered investigational or not medically necessary. Covered (medically necessary) interventions include POEM for achalasia and diffuse esophageal spasm, and gastric electrical stimulation (GES) and pyloroplasty for refractory gastroparesis when criteria are met per referenced InterQual criteria. Not medically necessary or investigational positions include G-POEM for gastroparesis and many endoscopic/implant therapies for GERD (including several endoscopic plication/suturing approaches, LINX/MSA, and other injection/implant techniques). The policy enumerates applicable CPT codes for these procedures and cross-references use of InterQual criteria for certain therapies. The evidence base and guideline support are characterized as variable with notable limitations in long-term durability and overall evidence quality for many endoscopic GERD therapies.

Key policy coverage positions and status

POEM CoverageCovered for Achalasia and Diffuse Esophageal Spasm (policy: proven and medically necessary)

G-POEM CoverageNot medically necessary for treatment of Gastroparesis (policy: unproven/not medically necessary)

GES CoverageCovered for refractory gastroparesis (diabetic or idiopathic) referencing InterQual criteria and Enterra HDE

GERD endoscopic/implant coverageMost endoscopic therapies and LINX/MSA considered unproven/investigational or not medically necessary in policy; many devices reviewed but long-term evidence limited

New Policy EntryPolicy listed as new with summary of changes dated 04/01/2026 (New Medical Policy)

Members 18 Years of Age and Older - GES and Pyloroplasty

Documentation Required

Use InterQual for GES and certain GERD/antireflux procedures

Use InterQual® criteria for gastric electrical stimulation and for specified GERD/antireflux procedures when making coverage determinations. Ensure documentation includes validated symptom scores where available, explains any variability in objective testing (e.g., gastric emptying protocols), and cites applicable benefit/contractual rules governing coverage decisions.

Apply InterQual clinical criteria for GES and for antireflux/GERD surgical procedures where indicated.
Include validated symptom score instruments (e.g., Gastroparesis Cardinal Symptom Index) in submitted documentation when available to support symptom burden and treatment response.
If objective testing methods vary from standard protocols, document the method and clinical rationale explaining how results support the diagnosis.
Reference the member’s benefit plan and applicable state contractual requirements (Indiana) when determining benefit coverage; medical necessity criteria alone do not guarantee coverage.

Members 18 Years of Age and Older - POEM and other procedures

Policy positions:

ALL of the following

Per oral endoscopic myotomy (POEM) procedure is proven and medically necessary for treating individuals with Achalasia or Diffuse Esophageal Spasm.
Per oral endoscopic myotomy (POEM) is unproven and not medically necessary for all other indications (e.g., Zenker's diverticula) due to insufficient evidence of efficacy.
Not medically necessary for indications beyond Achalasia or Diffuse Esophageal Spasm.
Gastric per oral endoscopic myotomy (G-POEM) is unproven and not medically necessary for the treatment of Gastroparesis.
The following for GERD are unproven and not medically necessary

Members Under 18 Years of Age

Coverage positions mirror adult policy for pediatric members where stated:

ALL of the following

GES therapy is proven and medically necessary for treating refractory Gastroparesis that has failed other therapies, or chronic intractable (drug-refractory) nausea and vomiting secondary to Gastroparesis of diabetic or idiopathic etiology.
Surgical pyloroplasty (open or laparoscopic) is proven and medically necessary for treating refractory Gastroparesis that has failed other therapies, or chronic-intractable (drug-refractory) nausea and vomiting secondary to Gastroparesis of diabetic or idiopathic etiology.
POEM is proven and medically necessary for treating individuals with Achalasia or Diffuse Esophageal Spasm.
POEM is unproven and not medically necessary for all other indications (e.g., Zenker's diverticula).

Evidence summaries and conclusions (grouped by procedure)

Summarized findings and limitations from the reviewed literature for each procedure:

ALL of the following

Per-Oral Endoscopic Myotomy (POEM): Evidence from randomized trials and systematic reviews indicates POEM is effective for type I and II achalasia and preferred for type III achalasia; POEM non-inferior to laparoscopic Heller myotomy (LHM) for symptom control at 2 years but with higher post-procedure gastroesophageal reflux; studies limited by lack of blinding, variable surgeon experience, and need for more multicenter randomized comparisons.
AGA practice update recognizes POEM as effective and preferred for type III achalasia.
Z-POEM: Zenker's POEM (Z-POEM): Emerging evidence (systematic reviews, retrospective cohorts) suggests comparable clinical success to flexible endoscopic septotomy (FES) in expert hands, but evidence limited by retrospective designs, variable definitions of success, short follow-up, and potential higher recurrence; long-term comparative effectiveness uncertain.
ECRI 2025 assessment found limited long-term data and high risk of bias.

Definitions

Term	Definition
Achalasia	Primary esophageal motor disorder with impaired relaxation of the esophagogastric junction and loss of organized peristalsis.
Diffuse Esophageal Spasm	Esophageal motility disorder with simultaneous, uncoordinated, or rapidly propagated contractions accompanied by dysphagia.
Gastroesophageal Reflux Disease (GERD)	Condition where lower esophageal sphincter relaxes too often or weakens allowing stomach acid to reflux into the esophagus.
Gastroparesis	Delayed gastric emptying in symptomatic patients; requires objective evidence of clearly delayed gastric emptying (scintigraphy reference standard).
POEM	Per-Oral Endoscopic Myotomy, an endoscopic technique for esophageal myotomy used to treat achalasia and spastic esophageal disorders.
Z-POEM	Zenker's Peroral Endoscopic Myotomy, an endoscopic technique for treating Zenker's diverticulum.
G-POEM	Gastric Per-Oral Endoscopic Myotomy, an endoscopic pyloromyotomy technique for refractory gastroparesis.
Stretta	Radiofrequency energy delivery system to the lower esophageal sphincter/gastroesophageal junction for treatment of GERD.
EFTP	Endoscopic Full-Thickness Fundoplication, an endoscopic suturing/plication procedure intended to treat GERD.
TIF	Transoral incisionless fundoplication (EsophyX device).
MUSE	Medigus Ultrasonic Surgical Endostapler transoral fundoplication device.
LINX / MSA	Magnetic sphincter augmentation device (LINX Reflux Management System).
GERD-HRQL	Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaire.
MSA / LINX	Magnetic sphincter augmentation device (LINX Reflux Management System) to augment the lower esophageal sphincter for GERD.
TIF / EsophyX / MUSE	Transoral incisionless fundoplication and related endoscopic devices to create fundoplication for GERD symptom control.
G-POEM (term repeated)	Gastric peroral endoscopic myotomy for treatment of refractory gastroparesis.
POEM (term repeated)	Peroral endoscopic myotomy for treatment of achalasia and spastic esophageal disorders.
Enterra Therapy System	Gastric electrical stimulation device approved under HDE for chronic, intractable nausea and vomiting secondary to diabetic or idiopathic gastroparesis in adults 18-70.
EFTP (duplicate definition)	Endoscopic full-thickness fundoplication/plication (endoscopic suturing device-based fundoplication).
GERDx™	Endoluminal therapy device for endoscopic full-thickness plication (investigational/not FDA-cleared as of cited assessment).

Coding

Applicable/Referenced Procedure Codes (for reference; codes with * are not managed for medical necessity review for Indiana at policy effective date)CPT

43210	Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed.
43257	Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease.
43284	Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e., magnetic band), including cruroplasty when performed.
43289	Unlisted laparoscopy procedure, esophagus.
43497	Lower esophageal myotomy, transoral (i.e., peroral endoscopic myotomy [POEM]).
43499	Unlisted procedure, esophagus.
43647	Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum.
43648	Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum.
43659	Unlisted laparoscopy procedure, stomach.
43881	Implantation or replacement of gastric neurostimulator electrodes, antrum, open.

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Prior Authorization

Prior authorization cross-reference

Certain CPT procedure codes listed in the policy that are marked with an asterisk are not managed for medical necessity review in Indiana as of the policy effective date. Providers should consult the most up-to-date Indiana prior authorization and notification list for UnitedHealthcare Community Plan of Indiana to determine current prior authorization requirements.

Codes marked with * in the policy are not managed for medical necessity review for Indiana at policy effective date
Refer to the UnitedHealthcare Community Plan of Indiana prior authorization and notification list for current PA requirements

Provider Actions & Documentation Requirements

Documentation Required

Use of third-party criteria

UnitedHealthcare may use third-party tools such as InterQual criteria to assist in administering health benefits. Providers should be prepared to supply documentation consistent with those third-party criteria when requested for coverage adjudication.

Be prepared to provide documentation consistent with InterQual when requested
InterQual may be applied to GES and antireflux surgery criteria as referenced

Clinical Thresholds & Outcome Measures

Study thresholds and variable definitions to inform adjudication

Eckardt score thresholdClinical success defined as Eckardt score ≤ 3 in achalasia studies (used in Werner and many POEM studies)

GCSI severe threshold> 2.3 on GCSI used to define severe gastroparesis (Martinek RCT inclusion)

G-POEM clinical success definitions (varied)Study definitions vary: decrease ≥1 point in GCSI (Stojilkovic) OR ≥50% reduction in total GCSI (Martinek RCT) OR study-specific criteria used in other reviews

G-POEM response criteria (example)Abdelfatah retrospective definition: decrease ≥1 point in average total GCSI and >25% decrease in at least 2 subscales

Note on heterogeneityHighlight: study definitions and response thresholds for G-POEM vary across systematic reviews and RCTs — important for adjudication

Validated instruments and documentation: Clinical studies referenced in the evidence base commonly used validated symptom and outcome instruments — for achalasia the Eckardt score (clinical success often defined as ≤ 3), for gastroparesis the Gastroparesis Cardinal Symptom Index (GCSI) with study-specific thresholds (e.g., severe defined as > 2.3 in some RCTs and response definitions ranging from ≥1-point reductions to ≥50% decreases), and for GERD trials instruments such as the GERD‑HRQL, GSRS, QOLRAD, or DeMeester/pH metrics. Providers are advised to document baseline and follow-up symptom scores and relevant objective testing (e.g., gastric emptying scintigraphy, pH/DeMeester, endoscopic findings) when evaluating and treating patients with these procedures to support clinical decision-making and potential coverage adjudication.

Revision History

04/01/2026policy_addedLatest

New Medical Policy

Policy Summary

PayerUnitedHealthcare

PolicyMinimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Indiana Only) – Community Plan Medical Policy

Policy CodePolicy CS079IN.04

Change TypeNew Medical Policy

Effective DateApr 1, 2026

Next Review Date

SourceLink

On This Page

Endoscopic therapies other than transoral incisionless fundoplication

Injection or implantation techniques

LINX Reflux Management System

Endoluminal therapy with GERDx™ is investigational, unproven, and not medically necessary for treating GERD as it has not received FDA approval.

Documentation Required

Medical record documentation requirement

The member's medical record must contain documentation that fully supports medical necessity. Required documentation includes relevant medical history, findings from the physical examination, and results of pertinent diagnostic tests or procedures. Records must be legible, maintained in the patient's chart, and made available upon request to support coverage review.

Relevant medical history
Physical examination findings
Results of pertinent diagnostic tests or procedures
Legible records available upon request

G-POEM is unproven and not medically necessary for treatment of Gastroparesis.

Unproven for treating GERD in pediatric members

Endoscopic therapies
Injection or implantation techniques
LINX Reflux Management System

Endoluminal therapy with GERDx™ is investigational, unproven, and not medically necessary for treating GERD (no FDA approval).

G-POEM: Gastric POEM (G-POEM): Systematic reviews and meta-analyses report clinical success in many patients with refractory gastroparesis (approximate pooled success rates ~70% at one year in some reviews), but overall evidence quality is low/very low; heterogeneity in patient etiology, variable definitions of success, many single-center series, and limited RCT data (one small RCT vs sham showed benefit at 6 months but notable adverse events).

ECRI assessment (updated 2024) indicates potential benefits but very low-quality data; larger multicenter RCTs vs sham or other treatments needed.

Stretta (Radiofrequency): Radiofrequency energy (Stretta) for GERD: Mixed evidence; some observational series and older RCTs yield symptomatic improvement and reduced PPI use in select patients, but higher-quality RCTs (e.g., Zerbib et al. 2020) showed no significant benefit over sham for primary endpoints; systematic reviews/ECRI/Hayes conclude evidence is low quality and effectiveness vs laparoscopic fundoplication uncertain.

Potential but unproven benefit; large, well-designed trials needed.

Endoscopic plication / EFTP and other endoscopic GERD therapies: Endoscopic plication/suturing / EndoCinch / Endoscopic full-thickness fundoplication (EFTP): Evidence limited and mixed. Older devices (EndoCinch) had poor long-term benefit. Recent RCTs (e.g., Kalapala 2022) of EFTP showed symptomatic improvement and reduced PPI dependence at 12 months compared with sham in a small trial, but overall evidence is limited by small sample sizes, variable PPI definitions, and short follow-up; network meta-analyses indicate some endoscopic/surgical interventions reduce PPI use versus PPI therapy, but objective reflux measures often unchanged.

Further long-term comparative data required.

Background: The policy summarizes clinical conditions and mechanisms relevant to the covered procedures: Achalasia and diffuse esophageal spasm are esophageal motility disorders treated by muscle disruption (POEM) to relieve outflow obstruction; gastroparesis is delayed gastric emptying (diagnosed by gastric emptying scintigraphy) with symptoms such as nausea and vomiting and may be managed by interventions such as gastric electrical stimulation (GES), surgical pyloroplasty, or pyloromyotomy techniques (including G-POEM) intended to improve gastric emptying; GERD arises from a weak or dysfunctional lower esophageal sphincter and has multiple endoluminal and surgical treatment strategies (radiofrequency Stretta, endoscopic plication/suturing, TIF/EsophyX, MUSE, and magnetic sphincter augmentation/LINX) aimed at restoring the antireflux barrier. Clinical evidence and guideline overview: randomized trials and systematic reviews support POEM as effective for achalasia (with some guidelines preferring POEM for type III achalasia) but note higher post-procedure reflux compared with laparoscopic Heller myotomy; G-POEM shows promising short-term clinical response (~~70% pooled 1-year success in some reviews) but overall evidence quality is low/very low and larger RCTs are needed; GES has mixed evidence with guideline conditional recommendations for select refractory gastroparesis cases and HDE/FDA labeling for Enterra in specified patients, but HTAs conclude effectiveness is uncertain due to low-quality data; endoscopic GERD therapies have heterogeneous, generally low-to-moderate quality evidence with limited long-term durability and inconsistent objective reflux outcomes, so many are considered investigational or not medically necessary outside stated indications.

Study / Source	Key finding
Werner et al. (2019) RCT POEM vs LHM	POEM non-inferior to LHM at 2 years: clinical success 83.0% vs 81.7% (difference 1.4 percentage points; 95% CI -8.7 to 11.4; p=0.007 for noninferiority).
Khan et al. (2017) pooled POEM for spastic disorders	Weighted pooled rate success ~87% for type III achalasia / overall SEDs WPR 87%; adverse events WPR 11-16%.
Mandarino et al. (2024) G-POEM pooled analysis	Approximately 70% clinical success at 1 year across 13 studies (952 patients); evidence considered limited/weak with heterogeneity.
Martinek et al. (2022) G-POEM RCT (sham)	15/21 success in G-POEM vs 4/20 in sham at 6 months; 10 SAEs with 3 related to G-POEM.
Zerbib et al. (2020) Stretta RCT (sham-controlled)	No significant difference between Stretta and sham at 24 and 48 weeks on days without heartburn, other symptoms, or PPI/antacid use.
Bell et al. (2019/2020) LINX (MSA) RCT vs double-dose PPI	At 6 months, 89% MSA reported relief of regurgitation vs 10% PPI; transient dysphagia 28% (MSA), ongoing dysphagia 4%.
Systematic reviews / ECRI / Hayes on G-POEM, Stretta, LINX	Assessments note low-to-very low quality evidence for many endoscopic therapies; LINX shows short-term effectiveness and high PPI discontinuation but long-term safety/erosion and device removal risks remain uncertain.