Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Idiopathic gastroparesis. 
Treatment: Outpatient procedure (43999 x 1) G-POEM (gastric peroral endoscopic myotomy).  

The insurer denied coverage for G-POEM. 

The denial is upheld. 

This case involves a female with a diagnosis of idiopathic gastroparesis. In an operative report, it was noted that the patient had a colonoscopy for diarrhea. The findings noted mild gastritis. Otherwise, it was a negative study. In a clinical note, the patient was seen for an evaluation and diagnosed with gastroparesis. She had intractable nausea and reported that her symptoms were progressively getting worse. She was on cyclobenzaprine and marijuana with some relief of nausea. Her weight was stable. She denied dysphagia and having Botox injections into the pylorus. A gastric emptying study was completed. The vital signs documented as blood pressure 120/74, pulse of 78, temperature 98.2 Fahrenheit, height of 67 inches, and weight of 207 pounds with a body mass index of 32.4. The exam findings of the patient were unremarkable. Her abdomen was soft, nondistended, and nontender. She had normal active bowel sounds. Her lung sounds were clear to auscultation. The provider stated that the patient would benefit from gastric peroral endoscopic pyloromyotomy. 

Per Mohan et. al. (2020), a systematic review and meta-analysis revealed that the G-POEM demonstrated clinical success in treating refractory gastroparesis. For idiopathic gastroparesis, prior treatment with botulinum injections and gastric stimulator appeared to have positive predictive effects on the 4-hour gastric emptying study results after the procedure. Outcomes seemed comparable with surgical pyloroplasty. Pioppo et. al. (2021), found that the G-POEM procedure may be less invasive, safer, and more efficacious procedure treatment for refractory gastroparesis as compared with surgical pyloromyotomy. A more recent study from Vosoughi, et. al. (2022) found that the procedure was safe but showed only modest overall effectiveness in the treatment of refractory gastroparesis. Further studies were required to identify the best candidates for the treatment. Unselective use of the procedure should be discouraged. 

In this case, the patient was diagnosed with refractory gastroparesis confirmed with gastric emptying study. The provider noted that options for the patient included surgical pyloromyotomy and feeding tube placement or G-POEM procedure. The provider indicated that there were numerous studies published demonstrating improvement in gastric emptying for the patient's symptoms. It has been shown to decrease hospitalization rate and improve quality of life. Based on the provided literature, some studies have found the treatment safe and effective for the patient's clinical presentation and diagnosis. Further studies are required to identify the best candidates for the procedure. The cited scientific evidence is conflicting for support of the procedure. It has been found safe, but studies have found varying outcomes ranging for modest to significant improvement in symptoms. Based on the literature, the treatment would be appropriate, safe, and effective for some patients. However, it has not been determined that this is the best treatment for the patient or that she is a good candidate for the procedure. While the patient has ongoing symptoms, the documentation did not identify that the she exhausted lower levels of care. It is considered necessary for the patient to trial less invasive treatments including Botox injections prior to consideration for the surgical procedure as literature is limited in supporting who the best candidates for the procedure would be. There are increased risks with more invasive surgical procedures when compared to lower levels of care. It is not likely that this procedure would be more beneficial for this patient. 

The carrier's denial of Outpatient procedure (43999 x 1) G-POEM (gastric per-oral endoscopic myotomy) should be upheld.