Peroral Endoscopic Myotomy for Esophageal Achalasia (POEM) Form

MEDICAL COVERAGE POLICY SERVICE: Peroral Endoscopic Myotomy (POEM) for Esophageal Achalasia Policy Number: 228 Effective Date: 08/01/2025 Last Review: 06/09/2025 Next Review: 06/09/2026 Page 1 of 5 Important note: Unless otherwise indicated, medical policies will apply to all lines of business. Medical necessity as defined by this policy does not ensure the benefit is covered. This medical policy does not replace existing federal or state rules and regulations for the applicable service or supply. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan documents. See the member plan specific benefit plan document for a complete description of plan benefits, exclusions, limitations, and conditions of coverage. In the event of a discrepancy, the plan document always supersedes the information in this policy. SERVICE: Peroral Endoscopic Myotomy (POEM) for Esophageal Achalasia PRIOR AUTHORIZATION: Not required. POLICY: Please review the plan’s EOC (Evidence of Coverage) or Summary Plan Description (SPD) for details. Note: Unless otherwise indicated (see below), this policy will apply to all lines of business. For Medicare plans, please refer to appropriate Medicare NCD (National Coverage Determination) or LCD (Local Coverage Determination). Although a non-Texas specific LCD exists, please use the criteria set forth below. For Medicaid plans, please confirm coverage as outlined in the Texas Medicaid Provider Procedures Manual | TMHP (TMPPM). If there are no applicable criteria to guide medical necessity decision making in the TMPPM, use the criteria set forth below. BSWHP may consider Peroral Endoscopic Myotomy (POEM) for Esophageal Achalasia medically necessary when the following criteria are met:

1. Member is age 18 years or older
2. Member has achalasia type I, II, or III diagnosed using esophageal manometry
3. Member has Eckardt symptom score of at least 3 Contraindications include:
4. Severe erosive esophagitis
5. Significant coagulation disorders
6. Liver cirrhosis with portal hypertension
7. Prior therapy that may compromise the integrity of the esophageal mucosa or lead to submucosal fibrosis (eg, radiation, endoscopic mucosal resection, or radiofrequency ablation) Note that previous therapies for achalasia, such as pneumatic balloon dilation, botulinum toxin injection, or surgical myotomy, are not contraindications to POEM Peroral endoscopic myotomy (POEM) for ANY other indication is considered experimental, investigational and unproven.

MEDICAL COVERAGE POLICY SERVICE: Peroral Endoscopic Myotomy (POEM) for Esophageal Achalasia Policy Number: 228 Effective Date: 08/01/2025 Last Review: 06/09/2025 Next Review: 06/09/2026 Page 2 of 5 BACKGROUND: Peroral endoscopic myotomy (POEM) is a less invasive alternative to laparoscopic myotomy for treatment of esophageal achalasia. POEM is a natural orifice transmural endoscopic surgery (NOTES) technique. The technique involves passing an endoscope through the esophagus, making a tunnel for access to the lower esophagus and cutting the muscle fibers in the lower esophagus and proximal stomach. The American Gastroenterological Association (AGA) states: POEM, laparoscopic Heller myotomy, and pneumatic dilation are effective therapies for type I and type II achalasia; the decision between these treatment modalities should be based on shared decision making, taking into account patient and disease characteristics, patient preferences, and local expertise. POEM should be considered the preferred treatment for type III achalasia. The current version of UpToDate review on “Overview of the Treatment of Achalasia” (Spechler, 2025) states that “Favorable outcomes for POEM have been reported in patients with achalasia conditions that often do not respond well to conventional therapies, such as "end stage" achalasia (markedly dilated, sigmoid esophagus), and in patients who have failed prior endoscopic and surgical achalasia treatments” and “The role of POEM in the treatment of achalasia continues to evolve, although there is a consensus that POEM is the procedure of choice for the treatment of type III achalasia. It has been suggested that patients undergoing POEM should be counseled regarding the increased risk of post- procedure reflux compared with other treatments.” MANDATES: None CODES: Important note: Due to the wide range of applicable diagnosis codes and potential changes to codes, an inclusive list may not be presented, but the following codes may apply. Inclusion of a code in this section does not guarantee that it will be reimbursed, and patient must meet the criteria set forth in the policy language. CPT Codes: 43497 - Lower esophageal myotomy, transoral (ie, peroral endoscopic myotomy [POEM]) CPT Not Covered: ICD10 codes: ICD10 Not covered: K22.0 Achalasia of cardia

MEDICAL COVERAGE POLICY SERVICE: Peroral Endoscopic Myotomy (POEM) for Esophageal Achalasia Policy Number: 228 Effective Date: 08/01/2025 Last Review: 06/09/2025 Next Review: 06/09/2026 Page 3 of 5 POLICY HISTORY: Status Date Action New 01/31/2017 New policy Reviewed 01/23/2018 No changes Reviewed 01/15/2019 No changes Reviewed 01/23/2020 No changes Reviewed 01/28/2021 No changes Updated 01/27/2022 Change status to POEM - may now be medically necessary Reviewed 01/26/2023 No changes Reviewed 01/02/2024 No change criteria. Clarified to use this policy for all LOBs, except Medicaid if TMPPM has guidance. Formatting changes, added hyperlink to TMPPM, beginning and ending note sections updated to align with CMS requirements and business entity changes Reviewed 06/09/2025 Updated criteria to include achalasia types I and II as well as Eckardt; include contraindications; update background section; added additional references #34, 35, and 36 Updated 08/11/2025 Removed “Medicare NCD or LCD specific InterQual criteria may be used when available.” REFERENCES: The following scientific references were utilized in the formulation of this medical policy. BSWHP will continue to review clinical evidence related to this policy and may modify it at a later date based upon the evolution of the published clinical evidence. Should additional scientific studies become available, and they are not included in the list, please forward the reference(s) to BSWHP so the information can be reviewed by the Medical Coverage Policy Committee (MCPC) and the Quality Improvement Committee (QIC) to determine if a modification of the policy is in order.

1. ASGE Standards of Practice Committee, Pasha SF, Acosta RD, et al. The role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc. 2014;79(2):191-201.
2. Barbieri LA, Hassan C, Rosati R, Romario UF, Correale L, Repici A. Systematic review and meta-analysis: efficacy and safety of POEM for achalasia. United European Gastroenterol J. 2015;3(4):325-334.
3. Bhayani NH, Kurian AA, Dunst CM, Sharata AM, Rieder E, Swanstrom LL. A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia. Ann Surg. 2014;259(6):1098-1103.
4. Chen X, Li QP, Ji GZ, et al. Two-year follow-up for 45 patients with achalasia who underwent peroral endoscopic myotomy. Eur J Cardiothorac Surg. 2015;47(5):890-896.

MEDICAL COVERAGE POLICY SERVICE: Peroral Endoscopic Myotomy (POEM) for Esophageal Achalasia Policy Number: 228 Effective Date: 08/01/2025 Last Review: 06/09/2025 Next Review: 06/09/2026 Page 4 of 5

5. Fisichella PM, Ferreres A, Patti MG. Peroral endoscopic myotomy for achalasia. JAMA Surg. 2015;150(8):806807.
6. Friedel D, Modayil R, Stavropoulos SN. Per-oral endoscopic myotomy: major advance in achalasia treatment and in endoscopic surgery. World J Gastroenterol. 2014;20(47):17746-17755.
7. Grimes KL, Inoue H, Onimaru M, et al. Double-scope per oral endoscopic myotomy (POEM): a prospective randomized controlled trial. Surg Endosc. 2015. Epub ahead of print. July 15, 2015. Available at: http://link.springer.com/article/10.1007%2Fs00464-015-4396-2. Accessed December 22, 2015.
8. Hoppo T, Thakkar SJ, Schumacher LY, et al. A utility of peroral endoscopic myotomy (POEM) across the spectrum of esophageal motility disorders. Surg Endosc. 2015. Epub ahead of print. April 7, 2015. Available at: http://link.springer.com/article/10.1007%2Fs00464-015-4193-y. Accessed December 22, 2015.
9. Hu JW, Li QL, Zhou PH, et al. Peroral endoscopic myotomy for advanced achalasia with sigmoid-shaped esophagus: long-term outcomes from a prospective, single-center study. Surg Endosc. 2015;29(9):2841-2850.
10. Hungness ES, Teitelbaum EN, Santos BF, et al. Comparison of perioperative outcomes between peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy. J Gastrointest Surg. 2013;17(2):228-235.
11. Imperiale TF, O’Connor JB, Vaezi MF, Richter JE. A cost-minimization analysis of alternative treatment strategies for achalasia. Am J Gastroenterol. 2000;95(10):2737-2745.
12. Inoue H, Sato H, Ikeda H, et al. Per-oral endoscopic myotomy: a series of 500 patients. J Am Coll Surg. 2015;221(2):256-
14. Jones R, Junghard O, Dent J, et al. Development of the GerdQ, a tool for the diagnosis and management of gastro- oesophageal reflux disease in primary care. Aliment Pharmacol Ther. 2009;30(10):1030-1038.
15. Jones EL, Meara MP, Schwartz JS, Hazey JW, Perry KA. Gastroesophageal reflux symptoms do not correlate with objective pH testing after peroral endoscopic myotomy. Surg Endosc. 2015. Epub ahead of print. June 27, 2015. Available at: http://link.springer.com/article/10.1007%2Fs00464-015-4321-8. Accessed December 22, 2015.
16. Kumagai K, Tsai JA, Thorell A, Lundell L, Håkanson B. Per-oral endoscopic myotomy for achalasia. Are results comparable to laparoscopic Heller myotomy? Scand J Gastroenterol. 2015;50(5):505-512.
17. Li QL, Chen WF, Zhou PH, et al. Peroral endoscopic myotomy for the treatment of achalasia: a clinical comparative study of endoscopic full-thickness and circular muscle myotomy. J Am Coll Surg. 2013;217(3):442451.
18. Ling TS, Guo HM, Yang T, Peng CY, Zou XP, Shi RH. Effectiveness of peroral endoscopic myotomy in the treatment of achalasia: a pilot trial in Chinese Han population with a minimum of one-year follow-up. J Dig Dis. 2014;15(7):352-358.
19. Liu XJ, Tan YY, Yang RQ, et al. The outcomes and quality of life of patients with achalasia after peroral endoscopic myotomy in the short-term. Ann Thorac Cardiovasc Surg. 2015;20;21(6):507-512.
20. Meara MP, Perry KA, Hazey JW. Economic impact of per oral endoscopic myotomy versus laparoscopic Heller myotomy and endoscopic pneumatic dilation [poster]. 2014. Society of American Gastrointestinal and Endoscopic Surgeons [website]. Available at: http://www.sages.org/meetings/annual-meeting/abstracts-archive/economic-impact-of-per-oral- endoscopic-myotomy-versus-laparoscopic-heller-myotomy-and-endoscopic-pneumatic-dilation
21. Moawad FJ, Wong RK. Modern management of achalasia. Curr Opin Gastroenterol. 2010;26(4):384-388.
22. National Institute for Health and Care Excellence (NICE). NICE Guidance >> Peroral endoscopic myotomy (POEM) for achalasia.
23. Available at: https://www.nice.org.uk/guidance/indevelopment/gid-ip1229. Accessed December 22, 2015.
24. O’Neill OM, Johnston BT, Coleman HG. Achalasia: a review of clinical diagnosis, epidemiology, treatment and outcomes. World J Gastroenterol. 2013;19(35):5806-5812.
25. Orenstein SB, Raigani S, Wu YV, et al. Peroral endoscopic myotomy (POEM) leads to similar results in patients with and without prior endoscopic or surgical therapy. Surg Endosc. 2015;29(5):1064-1070.
26. Patel K, Abbassi-Ghadi N, Markar S, Kumar S, Jethwa P, Zaninotto G. Peroral endoscopic myotomy for the treatment of esophageal achalasia: systematic review and pooled analysis. Dis Esophagus. 2015b. Epub ahead of print. July 14, 2015. Available at: http://onlinelibrary.wiley.com/doi/10.1111/dote.12387/abstract;jsessionid=799802636CF87C2B9CB9239A0D9C 8F45.f04t01. Accessed December 22, 2015.
27. Society of Thoracic Surgeons. Achalasia and Esophageal Motility Disorders. 2015. Available at: http://www.sts.org/patient- information/esophageal-surgery/achalasia-and-esophageal-motility-disorders.
28. Stefanidis D, Richardson W, Farrell TM, Kohn GP, Augenstein V, Fanelli RD. Guidelines for the Surgical Treatment of Esophageal Achalasia. Society of American Gastrointestinal and Endoscopic Surgeons [website]. 2011. Available at: http://www.sages.org/publications/guidelines/guidelines-for-the-surgical-treatment-of-esophageal-achalasia/. Accessed

MEDICAL COVERAGE POLICY SERVICE: Peroral Endoscopic Myotomy (POEM) for Esophageal Achalasia Policy Number: 228 Effective Date: 08/01/2025 Last Review: 06/09/2025 Next Review: 06/09/2026 Page 5 of 5 December 22, 2015.

27. Talukdar R, Inoue H, Nageshwar Reddy D. Efficacy of peroral endoscopic myotomy (POEM) in the treatment of achalasia: a systematic review and meta-analysis. Surg Endosc. 2015;29(11):3030-3046
28. Tang X, Gong W, Deng Z, et al. Comparison of conventional versus Hybrid knife peroral endoscopic myotomy methods for esophageal achalasia: a case-control study. Scand J Gastroenterol. 2015:1-7.
29. Ujiki MB, Yetasook AK, Zapf M, Linn JG, Carbray JM, Denham W. Peroral endoscopic myotomy: A short-term comparison with the standard laparoscopic approach. Surgery. 2013;154(4):893-897.
30. Vaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline: diagnosis and management of achalasia. Am J Gastroenterol. 2013;108(8):1238-1249.
31. Wei M, Yang T, Yang X, Wang Z, Zhou Z. Peroral esophageal myotomy versus laparoscopic Heller’s myotomy for achalasia: a meta-analysis. J Laparoendosc Adv Surg Tech A. 2015;25(2):123-129.
32. Yang S, Zeng MS, Zhang ZY, Zhang HL, Liang L, Zhang XW. Pneumomediastinum and pneumoperitoneum on computed tomography after peroral endoscopic myotomy (POEM): postoperative changes or complications? Acta Radiol. 2015;56(10):1216-1221.
33. Patel K, Abbassi-Ghadi N, Markar S, Kumar S, Jethwa P, Zaninotto G. Peroral endoscopic myotomy for the treatment of esophageal achalasia: systematic review and pooled analysis. Dis Esophagus. 2016 Oct;29(7):807-819.
34. UpToDate, “Overview of the treatment of achalasia”, Stuart J Spechler, MDJohn E Pandolfino, MD; Literature review current through: Apr 2025. This topic last updated: Oct 25, 2024.
35. UptoDate, “Peroral endoscopic myotomy (POEM)”, Khashab, Mouen Literature review current through: Apr 2025
36. Clinical Practice Update Volume 167, Issue 7p1483-1490 December 2024 “AGA Clinical Practice Update on Advances in Per-Oral Endoscopic Myotomy (POEM) and Remaining Questions —What We Have Learned in the Past Decade: Expert Review” Dennis Yang, Robert Bechara, Christy M. Dunst, & Vani J.A. Konda4 Note: Health Maintenance Organization (HMO) products are offered through Scott and White Health Plan dba Baylor Scott & White Health Plan, and Scott & White Care Plans dba Baylor Scott & White Care Plan. Insured PPO and EPO products are offered through Baylor Scott & White Insurance Company. Scott and White Health Plan dba Baylor Scott & White Health Plan serves as a third-party administrator for self-funded employer-sponsored plans. Baylor Scott & White Care Plan and Baylor Scott & White Insurance Company are wholly owned subsidiaries of Scott and White Health Plan. These companies are referred to collectively in this document as Baylor Scott & White Health Plan.
    RightCare STAR Medicaid is offered through Scott and White Health Plan in the Central Texas Medicaid Rural Service Area (MRSA); FirstCare STAR is offered through SHA LLC dba FirstCare Health Plans (FirstCare) in the Lubbock and West MRSAs; and FirstCare CHIP is offered through FirstCare in the Lubbock Service Area.