Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Esophageal Achalasia.
Treatment:  Surgical Services (Ambulatory Surgery POEM (Per Oral Endoscopic Myotomy)).

The health plan denied the surgical services (Ambulatory Surgery POEM (Per Oral Endoscopic Myotomy)).  The health plan determination is upheld.

This is a review for the medical necessity of Per Oral Endoscopic Myotomy (POEM) to treat achalasia.  This is a male patient, who has dysphagia due to type III achalasia documented endoscopically on imaging, as well as on esophageal manometry.  Therefore, the attending gastroenterologist would like to refer the patient for POEM to treat his achalasia.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Ambulatory Surgery, Per oral endoscopic myotomy (POEM), is not medically necessary for this patient.  

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 "pseudoachalasia" (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.  Per oral endoscopic myotomy (POEM), a minimally invasive endoscopic technique, is one of the most recent advances in the treatment of achalasia.  POEM is conceptually similar to a surgical myotomy without the inherent external incisions and post-operative care associated with surgery.  Several studies have established the short-term safety and efficacy of POEM.  Serious adverse events are rare with POEM.  They occur at a rate of < 0.1% with the most common serious event being perforation.  Another, albeit less serious, complication following POEM is GERD.  In carefully selected patients, some studies have shown short-term postoperative clinical symptoms of GERD following POEM is 10.9%, comparable to that of Laparoscopic Cardiomyotomy.  A study by Li QL and colleagues which followed over 500 patients who had the POEM procedure over 49 months showed that POEM is a highly safe and effective treatment for esophageal achalasia with favorable long-term outcomes.  However, there are no data regarding the long-term efficacy of the procedure (beyond 5 or 10 years) as opposed to a conventional or laparoscopic Heller myotomy.  According to current American Gastroenterological Association guidance, POEM to be 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.  Randomized, controlled studies comparing the long-term efficacy (~ 10 years) and safety of POEM vs Laparoscopic Heller Myotomy are needed before this procedure can routinely be recommended.