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Peroral endoscopic myotomy (POEM) is a procedure that utilizes the oral cavity to perform a myotomy, the surgical cutting of muscle, of the lower esophageal sphincter. POEM is conducted by guiding an endoscope through the esophagus, creating an incision that allows for access to the lower esophagus and gastroesophageal junction, followed by the cutting of muscle fibers located in the lower esophagus and stomach. Internal incisions are closed after completion of the myotomy.
POEM was developed for treatment of esophageal achalasia—a disorder characterized by the inability to relax the lower esophageal sphincter, resulting in difficulty swallowing and obstruction of the passage of food into the stomach. Other symptoms associated with this disorder include regurgitation, coughing, choking, aspiration pneumonia, esophagitis, ulceration, and weight loss. POEM may also be used for the treatment of spastic esophageal disorders. The POEM procedure is an alternative to laparoscopic Heller myotomy, another surgical procedure in which muscles of the lower esophageal sphincter are cut.
The POEM procedure has also been adapted to be performed in the stomach. The endoscopic pyloromyotomy (G-POEM) procedure myotomizes the pylorus rather than the lower esophageal sphincter. G-POEM may be used for treatment of gastroparesis, a syndrome of delayed gastric emptying.
POEM and G-POEM are endoscopic procedures and, therefore, are not subject to FDA regulations.
I. POEM for Type III Achalasia
Peroral endoscopic myotomy (POEM) may be considered MEDICALLY NECESSARY AND APPROPRIATE for patients who meet ALL of the following criteria:
II. Experimental/ Investigative Uses
Peroral endoscopic myotomy (POEM) is considered EXPERIMENTAL/INVESTIGATIVE for all other indications, including but not limited to type I and type II esophageal achalasia, due to the lack of clinical evidence demonstrating an impact on improved health outcomes.
Endoscopic pyloromyotomy (G-POEM) is considered EXPERIMENTAL/INVESTIGATIVE for all indications, including but not limited to gastroparesis, due to the lack of clinical evidence demonstrating an impact on improved health outcomes.
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Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
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CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.