ModifiedUnitedHealthcarePolicy CS079KY.12

Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Kentucky Only)

This policy governs coverage and medical necessity determinations for minimally invasive procedures to treat upper gastrointestinal conditions (e.g., GERD, gastroparesis, achalasia) for UnitedHealthcare members in Kentucky.

Policy Summary

PayerUnitedHealthcare

PolicyMinimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Kentucky Only)

Policy CodePolicy CS079KY.12

Change TypeTitle changeadditions to proven interventionsCPT code additions

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of prior medical therapy and objective testing to support medical necessity (e.g., PPI trial, pH/DeMeester, gastric emptying studies).

SourceLink

POLICY UPDATE CHANGES

Title changed from 'Minimally Invasive Procedures for Gastric and Esophageal Diseases (for Kentucky Only)' to current title and age limitation wording removed.

Gastric electrical stimulation (GES) therapy is proven and medically necessary for refractory gastroparesis or chronic intractable nausea and vomiting secondary to gastroparesis of diabetic or idiopathic etiology.

Surgical pyloroplasty (open or laparoscopic) is proven and medically necessary for refractory gastroparesis or chronic intractable nausea and vomiting secondary to gastroparesis of diabetic or idiopathic etiology.

CPT codes 43647, 43648, 43659, 43881, 43882, 64590, and 64595 were added to the Applicable Codes section.

InterQual CP references were updated and expanded for gastric stimulation and minimally invasive GERD procedures.

1Policy title changes

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Medical Necessity

GES — Covered indications

Covered when ALL of the following are met:

Gastric electrical stimulation (GES): 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.

Refer to InterQual CP: Procedures Gastric Stimulation for medical necessity clinical coverage criteria and to the FDA/HDE labeling information.

Pyloroplasty — Covered indication

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.

Included as a proven/medically necessary intervention per policy revision history.

POEM — Covered and not covered indications

Per oral endoscopic myotomy (POEM): POEM is proven and medically necessary for treating individuals with achalasia or diffuse esophageal spasm.

POEM is unproven and not medically necessary for other indications (e.g., Zenker's diverticula).

Endoscopic/endoluminal GERD therapies — Not medically necessary/investigational

Endoscopic therapies for GERD: The following endoscopic and implantable therapies are unproven and not medically necessary for treating GERD due to insufficient evidence of efficacy: endoscopic therapies other than transoral incisionless fundoplication (TIF), injection or implantation techniques (e.g., Plexiglas/PMMA, Durasphere), and the LINX Reflux Management System; endoluminal therapy with GERDx™ is investigational and not medically necessary because it lacks FDA approval.

Specific devices/procedures cited include Stretta, NDO Plicator, MUSE, EsophyX (TIF), Plexiglas (PMMA) injections, Durasphere, and LINX.

G-POEM — Not medically necessary

G-POEM: Gastric per oral endoscopic myotomy (G-POEM) is unproven and not medically necessary for the treatment of gastroparesis.

Evidence includes small RCTs and systematic reviews rated low to very low quality with limited long-term durability data.

Coverage considerations and criteria

Summary of clinical evidence and guideline positions to inform coverage decisions

GES for gastroparesis: Evidence summaries note inconsistent results across randomized and observational studies; some case series report symptom improvement but RCTs provide limited confirmation; device complications (e.g., stimulator/lead movement) and device removal rates of approximately 7%–12% have been reported.

ACG and AGA provide conditional guidance; Hayes HTA concluded additional randomized placebo-controlled studies are needed.

Pyloroplasty / pyloric interventions: Systematic reviews and guideline statements report symptomatic improvement and improved gastric emptying after pyloroplasty; some analyses favor pyloric interventions over GES for symptom relief.

SAGES supports laparoscopic pyloroplasty as an effective first-line surgical option for refractory gastroparesis.

POEM for achalasia: Multiple RCTs and systematic reviews show POEM is effective and non-inferior to laparoscopic Heller myotomy for symptom control with high clinical success rates, though associated with increased postoperative gastroesophageal reflux.

Procedure-specific evidence stance

Coverage considerations based on evidence summaries:

POEM for achalasia: POEM is recognized as an effective treatment for type I and type II achalasia and recommended as the preferred approach for type III achalasia; randomized trials show noninferiority or superiority versus PD and LHM for symptom control.

Prior authorization should require diagnostic confirmation of achalasia subtype and documentation of prior relevant treatments.

Z-POEM for Zenker's diverticulum: Z-POEM may be an alternative to flexible endoscopic septotomy in expert centers but current evidence is limited and lacks long-term comparative data; consider experimental/unproven stance or require additional justification.

Prospective long-term data are needed.

G-POEM for refractory gastroparesis: G-POEM demonstrates symptomatic benefit in some studies including a small sham-controlled RCT at 6 months, but overall evidence quality is low/very low and long-term durability and comparative effectiveness versus surgical pyloroplasty or GES remain inconclusive.

Coverage may be considered only with thorough documentation of refractory symptoms, objective testing, and specialty review; continued evidence development is recommended.

Evidence-informed coverage considerations

Coverage considerations should reflect the following evidence-based observations and selection factors:

Evidence and patient selection: Trials commonly required chronic/refractory symptoms, prior optimization of medical therapy (e.g., PPI for GERD), objective evidence where applicable (abnormal pH/DeMeester for GERD; gastric emptying scintigraphy for gastroparesis), and limits on hiatal hernia size for antireflux devices.see citations

These elements are derived from RCT inclusion criteria and guideline recommendations.

Procedural outcomes observed: Reported outcomes across devices include symptomatic improvement (e.g., GERD-HRQL reductions), decreased PPI use, and variable objective improvements (pH normalization, gastric emptying); durability and objective efficacy differ by procedure and study.variable

Device-specific evidence summaries should be consulted.

Safety considerations:

Coverage considerations and evidence-supported candidate criteria

Coverage considerations reflected by trial inclusion criteria and evidence quality

General candidate criteria: Patient has chronic GERD symptoms despite optimized PPI therapy; objective evidence of pathologic reflux (e.g., abnormal pH/DeMeester) and hiatal hernia size consistent with device indications (often < 3 cm for trials); absence of Barrett's esophagus or advanced esophagitis typically required in trials.as per trial criteria (e.g., hiatal hernia < 3 cm)

Derived from randomized trials and guideline inclusion criteria; apply device-specific thresholds as specified.

Device-specific evidentiary stance: TIF (EsophyX): RCTs show symptom and PPI-use reductions but long-term comparative data are limited; LINX (MSA): RCTs show control of regurgitation versus PPI with high PPI discontinuation but with risks of dysphagia and rare erosion; polymer injections: evidence insufficient and limited by small series.evidence quality variable

Use these evidentiary summaries to inform patient selection and authorization requirements.

Eligibility elements (trial/guideline–based)

Common eligibility elements reported in RCTs/guidelines for consideration of MSA or antireflux procedures:

Typical eligibility prerequisites reported in trials/guidelines: Patients with objective evidence of GERD, persistent troublesome regurgitation or heartburn despite optimized medical therapy; abnormal pH testing; hiatal hernia < 3 cm (or ≤2 cm for some endoluminal devices); BMI commonly limited (e.g., < 35 kg/m2 in some trials); absence of Barrett's esophagus or severe esophagitis (Los Angeles grade C/D) as applied in trial inclusion criteria.as specified (e.g., hiatal hernia < 3 cm; BMI thresholds per trial)

Elements derived from trial inclusion criteria and ACG guidance; these are not an exhaustive policy list and device-specific criteria apply.

InterQual-referenced medical necessity criteria

Coverage for certain minimally invasive procedures is governed by referenced InterQual CP clinical criteria and by documentation supporting medical necessity.

InterQual referral: Refer to InterQual CP: Procedures Gastric Stimulation for medical necessity clinical coverage criteria for gastric electrical stimulation and for minimally invasive procedures for GERD.

UnitedHealthcare uses InterQual as a primary source for these clinical criteria; documentation supporting the criteria may be required for prior authorization.

Proven/Medically Necessary Interventions for Gastroparesis

The policy explicitly states the following interventions are considered proven and medically necessary when criteria are met:

Gastric electrical stimulation (GES) for gastroparesis: GES therapy is proven and medically necessary for refractory gastroparesis that has failed other therapies, or chronic intractable (drug-refractory) nausea and vomiting secondary to gastroparesis of diabetic or idiopathic etiology.failed other therapies

See FDA/HDE information and InterQual CP for detailed medical necessity criteria.

Surgical pyloroplasty for gastroparesis: Surgical pyloroplasty (open or laparoscopic) is proven and medically necessary for refractory gastroparesis that has failed other therapies, or chronic intractable (drug-refractory) nausea and vomiting secondary to gastroparesis of diabetic or idiopathic etiology.failed other therapies

Surgical pyloroplasty was added to the list of proven interventions in the policy revision history.

Endoluminal therapy using the GERDx™ system is considered investigational and not medically necessary for treatment of gastroesophageal reflux disease (GERD). The policy notes GERDx™ lacks U.S. Food and Drug Administration (FDA) approval and is therefore classified as investigational in this context.

This stance is aligned with the policy's broader position that endoscopic full-thickness plication and other endoluminal therapies for GERD (aside from transoral incisionless fundoplication) have insufficient high-quality evidence to support routine coverage.

Procedures for which current evidence is insufficient to establish long-term safety and effectiveness—such as Z-POEM for Zenker's diverticulum—are considered investigational and may be excluded from coverage. The policy cites limited study sizes, short follow-up, and high risk of bias in available studies as reasons for this position.

Because published series and reviews lack adequate long-term comparative data and standardized post-procedure protocols, these procedures typically require additional high-quality evidence (larger prospective or randomized studies) before being considered medically necessary.

The policy identifies multiple endoscopic and implantation techniques for GERD as lacking sufficient high-quality evidence or long-term outcome data. Examples include endoscopic radiofrequency energy (Stretta), endoscopic plication/suturing systems (e.g., EndoCinch), polymer injection and implantation techniques (e.g., Plexiglas, Durasphere), and earlier-generation stapling/stapler-based devices.

These procedures are characterized by small or uncontrolled studies, heterogeneous populations, inconsistent outcome measures, and progressive loss of benefit over time in some series; therefore they are designated unproven and not medically necessary for routine coverage.

Procedures supported only by low-quality evidence, with high rates of loss to follow-up or demonstrated lack of durable long-term effectiveness, are considered investigational. The policy specifically cites endoscopic plication/suturing techniques and polymer injection/implantation approaches as examples where long-term outcomes and safety are not adequately established.

Given these evidence limitations, claims for such procedures may be subject to denial or require additional justification and documentation of investigational use.

Many randomized trials and device studies excluded patients with advanced esophagitis (Los Angeles Grade C/D) and individuals with Barrett's esophagus. Because these populations were commonly excluded from trial eligibility, the policy indicates they may not be appropriate candidates for the endoscopic or device-based GERD procedures evaluated in trials and may be excluded from coverage in those contexts.

Prior authorization and documentation requirements commonly reference absence of these advanced esophageal conditions consistent with trial inclusion criteria.

The FDA labeling for the Enterra gastric electrical stimulation (GES) system includes explicit contraindications. The label specifies the device should not be used in patients with gastric obstruction or pseudo-obstruction, prior gastric resection, prior fundoplication, eating disorders, history of seizures, primary swallowing disorders, chemical dependency, or psychogenic vomiting.

These device labeling exclusions inform coverage determinations and prior authorization reviews for GES, and documentation of eligibility consistent with FDA labeling may be required.

Benefit coverage and medical necessity determinations in this policy are subject to applicable federal, state, and contractual requirements. The policy notes that documentation may be required to assess whether a member meets clinical criteria but that such documentation does not guarantee coverage.

Patient medical records must fully support medical necessity and be available upon request; lack of required documentation may lead to denial of the requested service.

The following procedures are specifically identified as investigational or not medically necessary when performed for indications lacking sufficient evidence: POEM outside of achalasia/diffuse esophageal spasm (for example, POEM for Zenker's diverticulum), G-POEM for gastroparesis, and various endoscopic/implantation therapies for GERD including Stretta, EndoCinch-type suturing, polymer injections/implants, and other endoluminal techniques without robust long-term data.

The policy highlights that G-POEM evidence is very low-quality with limited long-term durability data and that Z-POEM and some GERD endoscopic therapies lack adequately sized comparative trials; therefore these indications are considered unproven.

Although gastric electrical stimulation (GES) is described elsewhere in the policy as proven and medically necessary for narrowly defined, refractory gastroparesis indications (see InterQual referral), the document also notes uncertainty in the broader evidence base. When GES is proposed outside the narrow FDA/HDE or guideline-supported indications, it may be considered not medically necessary due to inconsistent randomized evidence and documented device complications.

Prior authorization for GES should therefore confirm the member meets the specific, evidence- and labeling-based eligibility criteria before coverage is approved.

Endoscopic therapies for GERD that use radiofrequency energy (the Stretta system) are considered unproven and not medically necessary for routine coverage. The policy cites randomized sham-controlled data that failed to demonstrate a consistent benefit versus sham and systematic reviews/HTAs concluding overall evidence quality is low with substantial uncertainty.

The American College of Gastroenterology (ACG) guideline similarly does not recommend Stretta as an antireflux procedure due to inconsistent efficacy data.

EndoCinch and other endoscopic suturing or plication techniques have not demonstrated durable long-term benefit for many patients. Long-term follow-up studies and randomized trials show a high proportion of patients eventually require ongoing proton pump inhibitor (PPI) therapy or subsequent surgical intervention, and loss to follow-up and limitations in study design weaken the evidence for durable efficacy.

Consequently, these techniques are considered unproven and not medically necessary for routine coverage.

Polymer injection and implantation techniques (for example, PMMA/Plexiglas and pyrolytic carbon-coated bead products such as Durasphere) lack sufficient, high-quality evidence of safety and effectiveness. Systematic reviews and small case series report short-term symptom improvements in selected patients, but randomized comparative long-term data and consistent objective improvements (e.g., pH manometry) are lacking.

The policy therefore designates these injectable bulking and implantation approaches as investigational and not medically necessary for routine GERD management.

The American College of Gastroenterology (ACG) guideline does not recommend the use of radiofrequency energy (Stretta) as an antireflux procedure, issuing a conditional recommendation based on a low level of evidence due to inconsistent efficacy data.

This guideline position is referenced in the policy to support the stance that Stretta remains unproven for routine clinical use.

Language previously included in an earlier policy version stating that functional lumen imaging probe (FLIP) technology is unproven and not medically necessary for diagnosing achalasia has been removed in this revision. The policy history documents this change in the coverage rationale and supporting sections.

Applicable Procedure and Device Codes

Applicable CPT Codes (procedures listed)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.

1–10 of 14

1/2

Procedure Codes (document did not specify)mixed

not specified

The document sections provided do not list explicit CPT/HCPCS/ICD-10 codes for procedures (Stretta, TIF/EsophyX).

TIF / EsophyX codesmixed

Not provided

Document does not list exact CPT/HCPCS/ICD-10 codes for TIF/EsophyX

LINX / MSA codesmixed

Not provided

Document does not list exact CPT/HCPCS/ICD-10 codes for LINX/MSA

Polymer injection/implantation codesmixed

Not provided

Document does not list exact CPT/HCPCS/ICD-10 codes for polymer injections/implants

Device PMA identifiersmixed

P100049

LINX Reflux Management System PMA number (FDA)

Recent 510(k) notificationsmixed

K233240

GERDx-System 510(k) Number

Added Applicable CPT CodesCPT

43647
43648
43659
43881
43882
64590
64595

BMI (study inclusion detail)

BMI threshold< 40 kg/m2 (inclusion criterion in at least one MUSE study)

ContextReported as a trial inclusion criterion for a MUSE (Medigus Ultrasonic Surgical Endostapler) study of endoluminal fundoplication

Use for authorizationDocumented BMI should be included in prior authorization records when relying on trial-based eligibility

Authorization, Documentation, and Operational Guidance

Prior Authorization

Coding and authorization reference

Prior Authorization Required: Prior authorization is required for procedures referenced in this policy. Submit documentation that supports the medical necessity of the requested service. Inclusion of a code in this policy does not guarantee coverage or payment.

Include applicable CPT/HCPCS/ICD-10 codes on the authorization request
Authorization must reference policy number CS079KY.12 and the planned procedure

Prior Authorization

Prior authorization — GES justification

Gastric electrical stimulation (GES) requires prior authorization with clear justification that the member has refractory gastroparesis or chronic intractable nausea and vomiting secondary to diabetic or idiopathic gastroparesis and has failed prior standard therapies. Refer to InterQual CP: Procedures Gastric Stimulation for specific medical necessity criteria.

Document prior trial of standard medical therapies (see criteria below)
If member is <18 years, note that GES is indicated for refractory gastroparesis or chronic intractable nausea/vomiting secondary to diabetic or idiopathic gastroparesis (see policy age-specific notes)

Clinical Background and Scope

Gastroesophageal reflux disease (GERD) results from a weak or dysfunctional lower esophageal sphincter allowing gastric contents to reflux into the esophagus, which can lead to esophagitis, strictures, Barrett's esophagus and increased risk of adenocarcinoma. Gastroparesis is characterized by delayed gastric emptying with symptoms such as nausea, vomiting, early satiety and can lead to nutritional and metabolic complications; gastric emptying scintigraphy is the reference standard for diagnosis.

Per oral endoscopic myotomy (POEM) is an advanced endoscopic myotomy performed for achalasia and diffuse esophageal spasm and requires specialized endoscopic surgical expertise. The policy references InterQual criteria and FDA/HDE labeling where applicable and notes that coverage determinations depend on documented clinical criteria, prior therapy, and applicable regulatory or contractual requirements.

Definitions and Procedure Glossary

Achalasia definition

TermAchalasia

DefinitionA primary esophageal motor disorder of unknown etiology characterized by degeneration of the myenteric plexus, resulting in impaired relaxation of the esophagogastric junction (EGJ) and loss of organized peristalsis in the esophageal body.

SourceAmerican Society of Gastrointestinal Endoscopy (ASGE)

Diffuse Esophageal Spasm definition

TermDiffuse Esophageal Spasm

DefinitionRare esophageal motility disorder characterized by simultaneous, uncoordinated, or rapidly propagated contractions of normal amplitude accompanied by dysphagia.

Policy Summary

PayerUnitedHealthcare

PolicyMinimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Kentucky Only)

Policy CodePolicy CS079KY.12

Change TypeTitle changeadditions to proven interventionsCPT code additions

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of prior medical therapy and objective testing to support medical necessity (e.g., PPI trial, pH/DeMeester, gastric emptying studies).

SourceLink

On This Page

Prior Authorization

Prior authorization: show prior therapy and objective testing

Prior authorization requests must show prior therapy trials and objective testing results demonstrating refractory disease before approval will be considered. Provide documentation of medication trials, therapy duration, response, and objective testing (e.g., gastric emptying study, pH/manometry where applicable).

Document trials of optimized PPI therapy for GERD-related procedures (dose and duration)
For gastroparesis procedures, include gastric emptying scintigraphy (GES) results with timing and numeric values
List all medications tried (prokinetics, antiemetics, neuromodulators) including dates and clinical response

Documentation Required

Device approval documentation for prior authorization

Device-specific approval documentation must be provided for device implant procedures (e.g., Enterra GES, LINX, EsophyX). Include device model, FDA status (HDE, PMA, 510(k)), manufacturer, and any device-specific contraindications or labeling restrictions.

For Enterra (GES): include HDE documentation and confirm patient meets HDE indications and age limits
For LINX and other implantable devices: include preoperative testing used in pivotal trials (eg, pH testing, hiatal hernia size, manometry)
If off-label device use is proposed, provide rationale and supporting clinical evidence

Denial Risk

Evidence insufficiency may trigger denial

Insufficient or missing clinical evidence and documentation may result in denial of the prior authorization. Procedures with limited, low-quality, or inconsistent evidence (e.g., some GES, G-POEM, Stretta, endoscopic suturing/plication for certain indications) require robust documentation to justify medical necessity.

If clinical evidence is limited or conflicting, include rationale for why standard therapies are inadequate and why the requested procedure is expected to benefit this patient
Lack of objective testing or absent documentation of prior therapies increases the likelihood of denial

Denial Risk

Evidence limitations may prompt denials

When evidence is limited for a specific intervention or indication, denials are more likely unless documentation clearly demonstrates clinical severity, objective findings, and exhaustion of standard therapies. Examples include investigational uses or indications lacking high-quality RCTs or long-term outcomes.

Provide long-term outcome data from treating clinicians when available
For investigational indications, include peer-reviewed literature or specialty society guidance that supports the proposed use

Denial Risk

Device-specific contraindications may trigger denial

Device-specific contraindications noted in FDA labeling must be documented and assessed. For Enterra (GES), do not proceed with implantation in patients with gastric outlet obstruction or pseudo-obstruction, prior gastric resection, fundoplication, eating disorders, history of seizures, primary swallowing disorders, chemical dependency, or psychogenic vomiting.

If any contraindication is present, document the reason the device is still being considered or provide alternative plans
For implantable antireflux devices, document hiatal hernia size and absence of severe esophagitis or Barrett's where required by device labeling (eg, LINX trial criteria)

Denial Risk

Documentation-based denial risk

Medical record documentation must fully support medical necessity. Incomplete, illegible, or missing records may result in denial. Ensure all submitted records include relevant history, physical exam findings, results of diagnostic tests, prior treatment details, and objective outcomes measures.

Include symptom scores (e.g., GCSI, Eckardt) and documented change after prior therapies when available
Attach operative notes, endoscopy reports, imaging, and test reports referenced in the request

Documentation Required

Clinical severity and prior treatment documentation

Prior authorization review will assess clinical severity and prior treatments. For gastroparesis and related procedures, document severity scales and a clear timeline of prior conservative/medical and endoscopic/surgical treatments attempted and outcomes.

Include validated symptom scores (GCSI) or clinician-documented severity
Document dates and outcomes of prior pyloric interventions, botulinum toxin injections, pyloroplasty, or G-POEM if applicable

Documentation Required

Baseline objective testing and hiatal hernia size

Baseline objective testing, including gastric emptying scintigraphy (GES) for gastroparesis and hiatal hernia sizing for GERD procedures, must be included with authorization requests. Report numeric results, test dates, and whether tests were performed while off confounding medications when applicable.

Provide 4-hour GES values (percent retention) and date of study
Document hiatal hernia size measured by endoscopy or imaging and state method used (endoscopy, barium)

Step Therapy

Step therapy consideration for achalasia and GERD

Step therapy and optimization of medical therapy is expected prior to surgical or endoscopic intervention for conditions like achalasia and GERD. For achalasia, confirm that stepwise care was considered and that POEM is being used consistent with guideline-recommended indications.

For achalasia, document prior treatments (eg, pneumatic dilation, botulinum toxin) or rationale if POEM is first-line per type-specific guidance
For GERD-related procedures, document optimization of PPI therapy (dose and duration) before device-based interventions

Step Therapy

Step requirement: optimize PPI therapy first

Confirm that optimal medical therapy was attempted and documented before approval of procedures intended to replace or reduce medication use. For GERD-related procedures, authors of key trials required optimized PPI therapy (often double-dose for a trial period) prior to enrollment.

Document PPI name, dose, frequency, duration, and response (eg, twice daily omeprazole for at least 8 weeks where trial evidence required)
If PPI intolerance or contraindication exists, include documentation supporting inability to continue optimal therapy

Documentation Required

Confirm prior optimal medical therapy

Confirm prior optimal medical therapy for the individual before requesting procedures for gastroparesis or GERD. This includes trials of appropriate pharmacologic agents and documented inadequate response, intolerance, or contraindication.

For gastroparesis: document trials of prokinetic agents (eg, metoclopramide, erythromycin), antiemetics, dietary modifications, and other adjunctive therapies
For GERD: document adequate trial of PPI therapy and supportive objective testing showing persistent pathologic reflux where required