Does 43497 require prior authorization?

No, 43497 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 43497?

Medicare facility rate: $718.45. Non-facility rate: $718.45. Work RVU: 12.96.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

12.96

Facility

$718.45

Non-Facility

$718.45

Required documentation to support claims for POEM (e.g., operative report, diagnostic testing, medical necessity) is defined in LCD L38747; consult that document for specific record elements and prior authorization requirements.
Document history and physical exam including a standardized validated symptom assessment (Eckardt score ≥3) prior to POEM.
Document high-resolution esophageal manometry (HRM) results with Chicago Classification subclassification to confirm achalasia type.
Document contrast esophagram findings suggestive of achalasia (narrowed EGJ 'bird-beak', esophageal aperistalsis, or sigmoid/megaesophagus) prior to POEM.

Clinical indications and coverage criteria for Peroral Endoscopic Myotomy (POEM) are those specified in Local Coverage Determination L38747 and are not independently defined in this billing/coding guideline.
POEM is medically necessary for symptomatic, manometrically proven primary (idiopathic) achalasia classified as Chicago Classification types I, II, or III.
Prior achalasia therapies (pneumatic dilatation, botulinum toxin injection, or laparoscopic Heller myotomy) do not preclude coverage for POEM.
Per oral endoscopic myotomy (POEM) procedure is proven and medically necessary for treating individuals with Achalasia or Diffuse Esophageal Spasm. AGA: Stepwise approach for individuals presenting with GERD symptoms; when symptoms persist despite lifestyle changes and optimal medication use, management strategies should be tailored based on factors such as the integrity of the anti-reflux barrier, presence of visceral hypersensitivity and hypervigilance, confirmation of PPI-refractory GERD, sym [...]
Stretta System: approved for radiofrequency thermal ablation treatment of GERD.
Bard EndoCinch / NDO Plicator: approved for endoscopic suturing in treatment of GERD (historical approvals).

AETNA-CPB-0678 — Gastric Pacing / Electrical Stimulation and Gastroesophageal Per Oral Endoscopic Myotomy

A58287 — Billing and Coding: Peroral Endoscopic Myotomy (POEM)

L38747 — Peroral Endoscopic Myotomy (POEM)

UHC-POL-minimally-invasive-procedures-gerd-achalasia — Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases

UMR-POL-UMR-minimally-invasive-procedures-gerd-achalasia

Ask Verity about documentation requirements, denial risks, or coverage in your state.