Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia. 
Treatment: Peroral Endoscopic Myotomy (POEM) Procedure. 

The insurer denied the Peroral Endoscopic Myotomy Procedure. 
The health plan's determination is overturned. 

The patient is a female who is status post Heller myotomy several years ago. She has recurrent achalasia, and the high resolution manometry shows that she has Type II achalasia. She has severe dysphagia and weight loss related to her achalasia. Given her prior cardio myotomy the attending gastroenterologist would like to do a Peroral Endoscopic Myotomy (POEM) procedure to treat her Type II achalasia since it is less invasive and has been shown to beneficial in patients who have had prior Heller myotomy. 

The proposed health service or treatment Peroral Endoscopic Myotomy (POEM) Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Achalasia is a primary disorder of esophageal motility and typically presents with dysphagia to both solids and liquids but may be accompanied by regurgitation and chest pain. The gold standard for the diagnosis of achalasia is esophageal motility testing with manometry, which often reveals aperistalsis of the esophageal body and incomplete lower esophageal sphincter relaxation. The diagnosis is aided by complimentary tests, such as esophagogastroduodenoscopy and contrast radiography. 
Esophagogastroduodenoscopy is indicated to rule out mimickers of the disease known as "pseudo achalasia" (e.g., malignancy). Endoscopic appearance of a dilated esophagus with retained food or saliva and a puckered lower esophageal sphincter should raise suspicion for achalasia. Additionally, barium esophagography may reveal a dilated esophagus with a distal tapering giving it a "bird's beak" appearance. Several therapeutic modalities aid in the management of achalasia, the decision of which depends on operative risk factors. Conventional treatments include medical therapy, botulinum toxin injection, pneumatic dilation, and Heller myotomy. Dilation and myotomy are the most definitive treatment options. New emerging therapies include peroral endoscopic myotomy, placement of self-expanding metallic stents, and endoscopic sclerotherapy. 

According to current American Gastroenterological Association guidance, POEM is the preferred treatment option in type III achalasia when a longer myotomy is indicated. For other achalasia syndromes, POEM should be considered as a treatment option of comparable efficacy to laparoscopic Heller myotomy, albeit with no long-term outcomes data and minimal controlled outcomes data currently available. 
In randomized controlled study by Saleh and colleagues', patients with achalasia experiencing persistent or recurrent symptoms after laparoscopic Heller myotomy, POEM resulted in a significantly higher success rate than pneumatic dilatation, with a numerically higher incidence of grade A-B reflux esophagitis. The POEM procedure to treat achalasia in this patient with prior failed Nissen Fundoplication is appropriate and medically necessary. 

The health plan's determination regarding the proposed health service or treatment is overturned in whole.