Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia
Treatment: Professional/Outpatient Services (43497 x 1); Peroral Endoscopic Myotomy (POEM) procedure 
The insurer denied coverage for Professional/Outpatient Services (43497 x 1); Peroral Endoscopic Myotomy (POEM) procedure 
The denial is overturned.

Based upon the records provided, this reviewer disagrees with the insurer in denying the peroral endoscopic myotomy (POEM) as it was medically necessary for this patient with the diagnosis of achalasia. Rohof noted that using the Chicago classification, a diagnosis of achalasia is based on an elevated median integrated relaxation pressure (IRP) in combination with failed peristalsis or spasm. This patient had elevated IRP as well as failed contractions with underlying stenosis at the lower esophageal sphincter likely due to achalasia as per the provider. The procedure has been proven to be successful as noted in peer reviewed literature. Olson noted in a review that peroral endoscopic myotomy has been shown to be an effective and durable treatment option for achalasia with additional potential roles for the treatment of other esophageal motility disorders and Zenker's diverticulum. Lois noted that several professional practice guidelines recommend POEM as a potential first-line therapy for the management of achalasia, yet payers remain hesitant to reimburse for the procedure owing to unanswered questions regarding safety. They found the use of POEM is increasing rapidly; payers should recognize the totality of evidence and current treatment guidelines as they consider reimbursement for POEM. Dirks noted in a systematic review of comparative studies between POEM and Heller Myotomy (HM) or Pneumatic Dilation (PD) that POEM had similar safety outcomes to both HM and PD, including treatment-related serious adverse events. The authors concluded that POEM has similar outcomes to HM and greater efficacy than PD. Reflux remains a critical outcome with unknown long-term clinical significance due to insufficient data and inconsistent reporting. 

This procedure has the approval of the appropriate regulatory body, the Food and Drug Administration (FDA). 

The provider has shown that the patient has achalasia with an abnormal IRP as well as distal esophageal stenosis consistent with achalasia. In addition, the patient has been shown to have 100% (percent) failed swallows with 80% pan esophageal pressurization without premature contractions. In addition he has a 60% incomplete bolus clearance. The patient was therefore referred to the provider for definitive therapy for achalasia and in discussion with the patient the decision was made to proceed with POEM. The patient is an appropriate candidate for the procedure. 

The POEM is one of the available options for this patient and has been shown to be efficacious in treating achalasia and is performed in a minimally invasive fashion compared to Heller myotomy. Thus it is a reasonable alternative to standard invasive therapy of Heller myotomy.

The adverse risks are not increased compared to standard therapy. UpToDate noted that when performed by experienced operators, POEM is a safe procedure that is associated with a low rate of postoperative adverse events. 

In summary, the denial of Professional/Outpatient Services (43497 x 1); Peroral Endoscopic Myotomy (POEM) procedure and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.