Peroral Endoscopic Myotomy (POEM)

Peroral Endoscopic Myotomy (POEM) is an endoscopic procedure for the management of achalasia. POEM is an endoscopic procedure, which creates a tunnel in the submucosal layer of the esophagus and proximal stomach. Through this submucosal tunnel, an esophageal and gastric myotomy are made using a flexible endoscope. The procedure is performed perorally, without any incisions in the chest or abdomen.

POEM should only be performed by appropriately trained, experienced physicians in high-volume centers. These centers must have the available staff to address any potential adverse events from POEM immediately, including but not limited to gastrointestinal or cardio-thoracic complications.

Clinical Guideline Coverage Criteria

POEM may be considered medically necessary for adults (18 years and older) with symptomatic achalasia when ALL of the following criteria are met:

1. The Member has a confirmed diagnosis of Type III esophageal achalasia
2. The Member has failure of a previous treatment for achalasia (e.g. Botox, pneumatic dilation)
3. The Member has none of the following contraindications to POEM:
   • Severe erosive esophagitis
   • Significant coagulation disorders
   • Liver cirrhosis with portal hypertension
   • Severe pulmonary disease
   • Esophageal malignancy
   • Prior therapy that may compromise the integrity of the esophageal mucosa or lead to submucosal fibrosis, including recent esophageal surgery, radiation, endoscopic mucosal resection, or radiofrequency ablation

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Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia (POEM)

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