Per-Oral Endoscopic Myotomy

Policy ID: S-269-004

Section: Surgery

Effective Date: January 04, 2021

Revised Date: January 15, 2024

Revision Effective Date: March 04, 2024

Last Reviewed: January 16, 2024

Applies To: Commercial and Medicaid Expansion

Description

Per-oral endoscopic myotomy (POEM) is an endoscopic procedure used to treat swallowing disorders, most commonly achalasia. POEM is a procedure that uses endoscopic technology to guide an endoscope through the esophagus, creating a submucosal tunnel in the lower part of the esophagus to reach the inner circular muscle bundles of the lower esophageal sphincter to perform myotomy.

Criteria

POEM is considered medically necessary when ALL of the following criteria are met:

The individual is aged 18 years or older; and
The individual has been diagnosed with achalasia; and
The diagnosis of achalasia has been confirmed by a positive esophageal manometry, esophagogastroduodenoscopy (EGD) and barium swallow.

POEM not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer reviewed literature.

Procedure Code

43497

Diagnosis Codes

Covered Diagnosis Code for Procedure Code 43497

K22.0

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-19-2020 New Policy

Internal Medical Policy Committee 11-23-2021 Coding update-effective January 01, 2022

Removed procedure code 43499
Added procedure code 43497

Internal Medical Policy Committee 1-20-2022 Revision

Changed Title; and
Updated with clarifying language.

Internal Medical Policy Committee 1-26-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 1-16-2024 Revision - Effective March 04, 2024

Updated References

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-269-003