Appeal type: Medical necessity
Decision: Overturned

Diagnosis: gastroparesis.

Treatment: endoscopic pyloro-myotomy.

The insurer is denied coverage for endoscopic pyloro-myotomy.

The denial is overturned. 

This male patient has a history of adenocarcinoma and gastroparesis.

Based on the literature provided there is scientific evidence in peer reviewed literature to support and substantiate its improvement in health outcomes as well as its safety and effectiveness. Khashab noted in "Peroral endoscopic myotomy (POEM)" UpToDate: 2021 POEM for gastroparesis that several case reports show that G-POEM is safe, feasible, and effective in treating severe refractory gastroparesis.  For example, he noted: "In a retrospective study of seven patients who underwent endoscopic pyloromyotomy for gastroparesis, all procedures were carried out successfully without immediate complications. Six of the seven patients experienced significant symptomatic relief following the procedure, particularly with nausea and epigastric burning. At three months, a gastric emptying study was repeated in five patients with normalization in four. Late complications included one pyloric channel ulcer requiring endoscopic reintervention and one transient dysphagia. In another study of 30 patients with refractory gastroparesis, G-POEM was completed successfully in all patients. Adverse events occurred in two (6.7 percent) patients, including one pneumoperitoneum and one prepyloric ulcer. Clinical response was observed in 26 (86 percent) patients at a median follow-up of 5.5 months. Repeat gastric emptying scan was obtained in 17 patients, with normalization in 8 (47 percent) and improvement in 6 (35 percent). Another single-center study included 100 gastroparetic patients who had exhausted prior medical therapy and had a mixture of etiologies. In this study, the approach of the G-POEM was along the lesser curvature. There was a significant improvement in the Gastroparesis Cardinal Symptom Index Score (GCSI-Score). Among patients whose postoperative gastric emptying studies were available, 78 percent had better four-hour emptying with a mean improvement in retention by 23.6 percent. This included 57 percent of patients with normal gastric emptying post-surgery. Finally, he noted that "in an international multicenter study of 216 patients undergoing G-POEM, adverse events were encountered in 14 percent, most of which were mild and conservatively managed. The most common adverse events were abdominal pain, mucosotomy, and capnoperitoneum." 

As noted by Khashab in "Peroral endoscopic myotomy (POEM)" UpToDate: 2021 POEM for gastroparesis - "Initial management of gastroparesis consists of dietary modification, optimization of glycemic control and hydration, and pharmacologic therapy with prokinetic and antiemetic medications. Patients who are refractory to medical therapy may require surgical interventions in the forms of tube gastrostomy, subtotal gastrectomy, or pyloroplasty. Surgical pyloroplasty (e.g., Heineke-Mikulicz pyloroplasty) can lead to sustained improvement of symptoms in patients with refractory gastroparesis. Gastric peroral endoscopic myotomy (G-POEM), which is an endoscopic equivalent of surgical pyloroplasty, has been performed in a few centers for severe refractory diabetic gastroparesis."

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for endoscopic pyloro-myotomy is overturned.  The medical necessity is substantiated.