Anthem Blue Cross Connecticut SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis Form

This document addresses selected transendoscopic therapies for the treatment of gastroesophageal reflux disease (GERD), dysphagia and gastroparesis. This document does not address procedures that approach the esophagus through abdominal laparoscopic or open surgical approaches.

Note: For additional information, please see the following related documents:

• CG-SURG-101 Ablative Techniques as a Treatment for Barrett’s Esophagus
• SURG.00131 Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)

Position Statement

Medically Necessary:

Peroral endoscopic myotomy (POEM) is considered medically necessary when all the following criteria are met:

1. The individual is 18 years of age or older; and
2. Has a diagnosis of primary achalasia; and
3. POEM is being proposed as an alternative to pneumatic dilation or myotomy (open or laparoscopic); and
4. Eckardt symptom score is greater than 3; and
5. There is no history of previous open surgery of the stomach or esophagus.

Not Medically Necessary:

POEM is considered not medically necessary when the criteria above are not met, and for all other indications.

Investigational and Not Medically Necessary:

The following transendoscopic treatments for gastroesophageal reflux disease, dysphagia and gastroparesis are considered investigational and not medically necessary for all indications:

1. Endoluminal gastric plication;
2. Endoscopic submucosal injection of bulking agents, beads or other substances;
3. Gastric peroral endoscopic myotomy or peroral pyloromyotomy;
4. Transendoscopic gastroplasty;
5. Transesophageal radiofrequency therapy (note: this does NOT include treatment of Barrett’s Esophagus with radiofrequency energy);
6. Transoral incisionless fundoplication.