Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Type III Achalasia
Treatment:  POEM
The health plan should cover the proposed POEM for the management of achalasia in this patient. 

The patient is a female with history of acute onset of dysphagia, for which she was evaluated at the outside hospital and diagnosed with type III achalasia based upon the high resolution manometry.  She underwent Botox injection of the esophagus with temporary relief of her symptoms.  Due to dysphagia and inability to eat, she has lost significant weight.  She was transferred to the current tertiary care center for further evaluation and management of achalasia.  She underwent repeat high resolution manometry, esophagogastroduodenoscopy (EGD) and Endoflip study, barium swallow and diagnosis of type III achalasia was confirmed.  The attending physician (AP) is recommending peroral endoscopic myotomy (POEM) for the management of achalasia.

POEM is indicated for achalasia; it is effective in patients of all ages and in every stage and subtype of the condition.  POEM is also successful after failure of, or relapse from, all other treatments for achalasia (eg, endoscopic botulinum toxin injection, pneumatic dilation, laparoscopic Heller myotomy).  Unlike laparoscopic Heller myotomy, POEM is indicated in spastic disorders of the esophagus such as type III achalasia, jackhammer esophagus, and distal esophageal spasm.  These conditions all require a long myotomy, which cannot be easily accomplished by the laparoscopic transabdominal approach.  Other situations in which POEM is preferable to laparoscopic Heller myotomy include in patients who have had prior esophagogastric surgery or in patients who may be anticipated to need bariatric surgery in the future.    

POEM has had an excellent record of efficacy and safety.  Clinical and physiologic outcomes have been comparable to those of the traditional laparoscopic Heller myotomy.  POEM combines the main benefits of the laparoscopic Heller myotomy with the ease of a minimally invasive endoscopic procedure.  Unlike the laparoscopic Heller myotomy, POEM does not include an antireflux procedure; thus, there are concerns regarding the development of gastroesophageal reflux disease as a result of the myotomy.  However, POEM does not require disruption of the natural antireflux barriers that are taken down during the dissection performed during a laparoscopic Heller myotomy.  The need for patients to undergo an antireflux operation after POEM is extremely uncommon; therefore, it is difficult to conclude that all patients undergoing an esophageal myotomy require a simultaneous antireflux procedure.

The requested POEM is likely to be more beneficial than any standard treatment(s) for the patient's condition.

The requested POEM procedure is likely to be more beneficial than any standard treatment for the management of Achalasia in this patient.  Pneumatic dilation is the least invasive procedure, but it often requires repeated treatments.  Fear of perforation, which occurs at a rate of about two percent per procedure, has reduced its popularity.  Laparoscopic Heller myotomy is also the most invasive of the three options, and it is associated with a longer recovery time and a higher risk of complications.  POEM is less intrusive and invasive procedure than Heller myotomy, and it has much lower recovery time and lower complications, and lower morbidity and mortality than Heller's myotomy.