Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroparesis

Treatment: Peroral Endoscopic Myotomy [POEM] procedure; code 43999 (usual procedure of the stomach) x (times) 1

The insurer denied coverage for the POEM procedure; code 43999 x 1.

The denial is upheld.

Gastroparesis is a chronic and debilitating disorder. Gastric-emptying scintigraphy is the only objective testing with symptoms for all patients with gastroparesis.
The evolving Peroral Endoscopic Pyloromyotomy, Gastric Peroral Endoscopic Myotomy (G-POEM) is a minimally invasive, flexible endoscopic procedure that is emerging as a new treatment option for select patients with refractory gastroparesis. 

Gastroparesis is a heterogeneous disorder, and not all patients with gastroparesis will have pyloric dysfunction. Thus, not all patients will benefit from G-POEM.

G-POEM is another pyloric-directed therapy, such as surgical pyloroplasty and pyloric stenting. Mostly retrospective reports have shown to improve symptoms of gastroparesis. Thus, G-POEM is an option for these pyloric-directed therapies.

From the American Gastroenterological Association (AGA), "The clinical response rate, as determined by symptomatic improvement, following G-POEM reached 73 to 86 percent after up to 12 months of follow-up. The overall complication rate of G-POEM is low, ranging from 0 to 6.7 percent. Available data suggest that it improves symptoms of gastroparesis (measured by an improvement in the Gastroparesis Cardinal Symptom Index [GCSI]), improved quality of life (as measured by an improvement in 36-Item Short Form Health Survey score) and decreased gastric emptying time during short- and mid-term follow-up in as many as 70 percent of patients. Serious adverse events have been rare but have included gastrointestinal bleeding, pyloric ulcer and tension capnoperitoneum. The long-term effectiveness of G-POEM is still unknown."

Furthermore, "The procedure is technically feasible and safe, and, in the hands of an experienced specialist, it has a low risk of complications. However, it is a technically challenging procedure compared with esophageal peroral endoscopic myotomy due to antral contractions, curved submucosal tunnel, extensive vascularity and a very thin duodenal wall, which predisposes patients to a high risk of perforation."

G-POEM is an option for patients with "refractory gastroparesis" whose predominant symptoms are "nausea and vomiting." G-POEM is not ideal for patients whose predominant symptoms are "abdominal pain and bloating." In addition, "patients taking long-term narcotic therapy and those with end-organ damage due to long-term diabetes are not ideal candidates for the procedure because they are unlikely to benefit from it."

The use of pyloric diagnostic techniques such as impedance planimetry could potentially be used to identify a subgroup of patients for whom endoscopic techniques for pyloric-directed therapies could be utilized.

Compared with surgical pyloroplasty, G-POEM is more appealing to patients because it is a minimally invasive endoscopic procedure, provides shorter lengths of hospital stay, and is a less painful procedure. 

G-POEM results, at this time, are derived from small retrospective studies. Large, prospective, randomized trials are needed. There are several limitations that exist because a gold standard does not exist to which the effectiveness of G-POEM can be compared. 

The procedure is not likely to be more beneficial that any standard treatments.

The carrier's denial of the POEM procedure; code 43999 x 1 should be upheld.