Achalasia and Gastroesophageal Reflux Disease (GERD) - Minimally Invasive Procedures Form

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Achalasia and Gastroesophageal Reflux Disease (GERD) - Minimally Invasive Procedures - Medical Policy
Updated Revision Effective: 10/1/2025 Policy Number:

UM904POL

Approval Date: 9/9/2025

Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Esophageal achalasia is an uncommon disorder that is characterized by the degeneration of ganglion cells of the esophageal myenteric plexus in the lower esophageal wall that leads to reduced peristaltic activity. This reduction or absence in primary peristaltic waves takes place in the distal lower two thirds of the esophagus that can make it difficult for individuals to swallow. Degeneration of the esophageal muscle in addition to the nerves that control these muscles can lead to complications such as regurgitation, coughing, choking, aspiration pneumonia, esophagitis, ulceration, and weight loss. The estimated prevalence in the United States of 10 cases per 100,000 with an incidence of 0.6 cases per 100,000 per year. The three types of achalasia defined by the Chicago Classification (CC, version 4.0 [CC-4]) include:

• Type I (Classic Achalasia) – Swallowing results in no significant change in esophageal pressurization. According to CC-4, type I achalasia has 100 percent failed peristalsis as indicated by a distal contractile integral (DCI, an index of the strength of distal esophageal contraction) <100 mmHg·s·cm.

• Type II – Swallowing results in simultaneous pressurization that spans the entire length of the esophagus. According to CC-4, type II achalasia has 100 percent failed peristalsis and pan-esophageal pressurization seen in ≥20 percent of swallows.

• Type III – (Spastic Achalasia) – Swallowing results in premature and often lumen-obliterating contractions or spasms. According to CC-4 criteria, type III achalasia has no normal peristalsis and premature (spastic) contractions with distal latency <4.5 seconds and DCI >450 mmHg·s·cm seen in ≥20 percent of swallows.

Treatment for achalasia has traditionally included pharmacotherapy such as injections with botulinum toxin, pneumatic dilation, and laparoscopic Heller myotomy. Although the last two are considered the standard treatments because of higher success rates and relative long-term efficacy compared with pharmacotherapy and botulinum toxin injections, they both are associated with a perforation risk of about 1%. Heller myotomy is the most invasive of the procedures, requiring laparoscopy and surgical dissection of the esophagogastric junction. One year response rates of 86% and rates of major mucosal tears requiring subsequent intervention of 0.6% have been reported.

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Peroral endoscopic myotomy (POEM) is an endoscopic procedure developed in Japan. POEM is performed with the patient under general anesthesia. An incision is made in the distal esophagus, and a submucosal tunnel is created with the endoscope. The circular smooth muscle is then cut extending to the proximal stomach. POEM differs from laparoscopic surgery, which involves complete division of both circular and longitudinal muscle layers, while POEM entails cutting the dysfunctional muscle fibers that prevent the LES from opening allows food to enter the stomach more easily.

Gastric peroral endoscopic myotomy (G-POEM) procedure involves tunneling an endoscope down the esophagus toward the esophageal-gastric junction. A surgeon performs the myotomy by cutting only the inner, circular LES muscles through a submucosal tunnel created in the proximal esophageal mucosa.

 Line of Business

Commercial:
Refer to criteria under the Policy section in this medical policy.

Medicaid – BeHealthy:
Refer to criteria under the Policy section in this medical policy. There are no MassHealth guidelines for Peroral endoscopic myotomy (POEM)

Medicare:
• Refer to criteria under the Policy section in this medical policy. Medicare does not have a National Coverage Determination (NCD) or a Local Coverage Determination (LCD) for Peroral endoscopic myotomy (POEM) • Health New England follows Local Coverage Determination (LCD) L35080 for Select Minimally Invasive GERD Procedures for other endoscopic anti-reflux procedures. https://www.cms.gov/medicare-coverage- database/search.aspx

Policy

I. Criteria for approval of POEM:

A. POEM is considered MEDICALLY NECESSARY when ALL the following criteria are met:

1. 18 years of age or older; AND

2. Achalasia type I, II, III based on esophageal motility testing; AND

3. Eckardt symptom score is greater than three (see policy guidelines).

   B. POEM for ANY other indication is considered NOT MEDICALLY NECESSARY.

   II. Criteria for approval of G-POEM:

   A. Gastric peroral endoscopic myotomy (G-POEM) is considered medically necessary for the treatment of refractory gastroparesis when ALL the following criteria are met:

   1. absence of mechanical obstruction confirmed by Esophagogastroduodenoscopy (EGD); AND

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2. a gastric emptying scintigraphy (GES) has confirmed delayed gastric emptying with gastric retention > 20% at four hours: AND

3. chronic, intractable nausea and vomiting secondary to gastroparesis AND;

4. failure of conservative medical management, including dietary modification, prokinetics and antiemetics.

   B. G-POEM for ANY other indication is considered not MEDICALLY NECESSARY.

   III. The following POEM procedures are considered EXPERIMENTAL/ INVESTIGATIONAL

5. Diverticular peroral endoscopic myotomy (D-POEM)

6. Zenker peroral endoscopic myotomy (Z-POEM)

   IV. The following endoscopic anti-reflux procedure for gastroesophageal reflux disease (GERD), or any other indication, are considered EXPERIMENTAL/ INVESTIGATIONAL for Commercial and MassHealth. Covered by Medicare following LCD L35080, Select Minimally Invasive GERD Procedures.

7. Transoral incisionless fundoplication (TIF) (e.g., EsophyX™, MUSE System)

   V. The following endoscopic anti-reflux procedures for gastroesophageal reflux disease (GERD), or any other indication, are considered EXPERIMENTAL/ INVESTIGATIONAL for all lines of business

8. Radiofrequency energy to the gastroesophageal junction (e.g., Stretta® System)

9. Endoluminal gastroplasty/gastroplications (e.g., Medigus Ultrasonic Surgical Endostapler [Muse™] System, GERDx™)

10. Injection/implantation of biocompatible material (e.g., plexiglas or polymethylmethacrylate [PMMA], Durasphere™)

11. Magnetic sphincter augmentation (e.g., LINX™ Reflux Management System)

12. Resection and plication (RAP) (e.g., Apollo Overstitch)

    Policy Guidelines and Definitions

    Policy Guidelines:

    Eckardt score for symptomatic evaluation in achalasia

    Score
    Weight loss (kg)
    Dysphagia
    Retrosternal Pain
    Regurgitation 0 None None None None 1 < 5 Occasionally Occasionally Occasionally 2 5-10 Daily Daily Daily 3

    10 Each Meal Each Meal Each Meal

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Definitions:

Gastroesophageal Reflux Disease (GERD): A condition where the lower esophageal sphincter (LES) relaxes too often or weakens which allows stomach acid to flow backward (or reflux) into the esophagus.

Contraindications to the POEM procedure:

1. Severe erosive esophagitis

2. Coagulation disorders

3. Liver cirrhosis with portal hypertension

4. Esophageal malignancy

5. Prior therapy for achalasia that may compromise integrity of the esophageal mucosa

6. Prior therapy that may lead to submucosal fibrosis (i.e., radiofrequency ablation, radiation therapy or endoscopic mucosal resection)

   Coding Guidance

   Code
   Description
   Coverage CPT

   43210 Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed E&I Commercial and MassHealth PA for Medicare Advantage 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 E&I
   43284 Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed E&I
   43497 Lower esophageal myotomy, transoral (ie, peroral endoscopic myotomy [POEM])
   PA 43499 Unlisted procedure, esophagus PA required when used to describe G-POEM E&I when used to describe procedures in sections III or IV
   43999 Unlisted procedure, stomach (Used to describe G-POEM) 49999 Unlisted procedure, abdomen, peritoneum and omentum PA = prior authorization required E&I=experimental and investigational

   CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

   Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

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References

Chung CS, Huang TY, Lin CL, Chiang CH, Chen KC, Wu JM, et al. Efficacy and safety of gastric peroral endoscopic myotomy (G-POEM) for refractory gastroparesis: 3-year follow up results. J Formos Med Assoc. 2022 Jul;121(7):1334-1341.

Aziz M, Gangwani MK, Haghbin H, Dahiya DS, Sohail AH, Kamal F, et al. Gastric peroral endoscopic myotomy versus surgical pyloromyotomy/pyloroplasty for refractory gastroparesis: systematic review and meta-analysis. Endosc Int Open. 2023 Apr 4;11(4):E322-E329.

Hernández Mondragón OV, Contreras LFG, Velasco GB, Pineda OMS, Carrillo DMC, Perez EM. Gastric peroral endoscopic myotomy outcomes after 4 years of follow-up in a large Page 53 of 68 Medical Coverage Policy: 0019 cohort of patients with refractory gastroparesis (with video). Gastrointest Endosc. 2022 Sep;96(3):487-499.

Khashab MA, Wang AY, Cai Q. AGA Clinical Practice Update on Gastric Peroral Endoscopic Myotomy for Gastroparesis: Commentary. Gastroenterology. 2023 Jun;164(7):1329- 1335.e1

Khashab MA, Vela MF, Thosani N, Agrawal D, Buxbaum JL, Abbas Fehmi SM, Fishman DS, Gurudu SR, Jamil LH, Jue TL, Kannadath BS, Law JK, Lee JK, Naveed M, Qumseya BJ, Sawhney MS, Yang J, Wani S. ASGE guideline on the management of achalasia. Gastrointest Endosc. 2020 Feb;91(2):213-227.e6. doi: 10.1016/j.gie.2019.04.231. Epub 2019 Dec 13. PMID: 31839408.

Kohn GP, Dirks RC, Ansari MT, Clay J, Dunst CM, Lundell L, Marks JM, Molena D, Rooker C, Saxena P, Swanstrom L, Wong RK, Pryor AD, Stefanidis D. SAGES guidelines for the use of peroral endoscopic myotomy (POEM) for the treatment of achalasia. Surg Endosc. 2021 May;35(5):1931-1948. doi: 10.1007/s00464-020-08282-0. Epub 2021 Feb 9. PMID: 33564964.

Vaezi, Michael F. MD, PhD, MSc, FACG1; Pandolfino, John E. MD, MS, FACG2; Yadlapati, Rena H. MD, MHS (GRADE Methodologist)3; Greer, Katarina B. MD, MS4; Kavitt, Robert T. MD, MPH5. ACG Clinical Guidelines: Diagnosis and Management of Achalasia. The American Journal of Gastroenterology 115(9):p 1393-1411, September 2020. | DOI: 10.14309/ajg.0000000000000731

Kahrilas PJ, Katzka D, Richter JE. Clinical Practice Update: The Use of Per-Oral Endoscopic Myotomy in Achalasia: Expert Review and Best Practice Advice From the AGA Institute. Gastroenterology. 2017 Nov;153(5):1205-1211. doi: 10.1053/j.gastro.2017.10.001. Epub 2017 Oct 6. PMID: 28989059; PMCID: PMC5670013.

Ahmed, Y, Othman, M, Peroral endoscopic myotomy (POEM) for Achalasia, Journal of Thoracic Disease (August 11, 2019), PMID 31489229,
Peroral endoscopic myotomy (POEM) for achalasia - PMC (nih.gov)

Poem is a Cost-Effective Procedure: Cost-Utility Analysis of Endoscopic and Surgical Treatment Options in the management of Achalasia. https://www.sages.org/meetings/annual-meeting/abstracts-archive/poem-is-a-cost-effective-procedure-cost- utility-analysis-of-endoscopic-and-surgical-treatment-options-in-the-management

von Renteln D, Inoue H, Minami H, et al. Peroral endoscopic myotomy for the treatment of achalasia: A prospective single center study. Am J Gastroenterol 2012;107:411–7.

Swanstrom LL, Rieder E, Dunst CM. A stepwise approach and early clinical experience in peroral endoscopic myotomy for the treatment of achalasia and esophageal motility disorders. J Am Coll Surg 2011;213(6):751–6.

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Evensen H, Kristensen V, Larssen L, et al. Outcome of peroral endoscopic myotomy (POEM) in treatment-naive patients. A systematic review. Scand J Gastroenterol 2019;54(1):1–7.

Andolfi C, Fisichella PM. Meta-analysis of clinical outcome after treatment for achalasia based on manometric subtypes. Br J Surg 2019;106(4):332–41.

Kumbhari V, Tieu AH, Onimaru M, et al. Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of type III achalasia in 75 patients: A multicenter comparative study. Endosc Int Open 2015;3(3):E195–201.

Khan MA, Kumbhari V, Ngamruengphong S, et al. Is POEM the answer for management of spastic esophageal disorders? A systematic review and meta-analysis. Dig Dis Sci 2017;62(1):35–44.

Zhang W, Linghu EQ. Peroral endoscopic myotomy for type III achalasia of Chicago classification: Outcomes with a minimum follow-up of 24 months. J Gastrointest Surg 2017;21(5):785–91.

Ponds FA, Fockens P, Lei A, et al. Effect of peroral endoscopic myotomy vs pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia: A randomized clinical trial. JAMA 2019;322(2):134–44.

Werner YB, Hakanson B, Martinek J, et al. Endoscopic or surgical myotomy in patients with idiopathic achalasia. N Engl J Med 2019;381(23):2219–29.

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 9/2022 Original policy effective date 10/2023 Changes made to policy title and medical necessity criteria. Medicare LCDs added. References were updated. 1/2024 Added Line of Business section, no changes to criteria.
8/2024 Gastric peroral endoscopic myotomy (G-POEM) changed from experimental/investigational to covered with prior authorization.
References added related to G-POEM 8/2025 Annual review. Minor changes with changing POEM and GPOEM to not medically necessary except in covered circumstances.

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Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.