S0016
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Key Coverage Criteria
- Peroral endoscopic myotomy (POEM) is consideredmedically necessaryfor individuals whenallof the following criteria are met:The individual has a diagnosis of primary achalasia;andPOEM is being proposed as an alternative to pneumatic dilation or myotomy (open or laparoscopic);andEckardt symptom score is greater than 3.
- The individual has a diagnosis of primary achalasia;and
- POEM is being proposed as an alternative to pneumatic dilation or myotomy (open or laparoscopic);and
- Eckardt symptom score is greater than 3.
- Transoral incisionless fundoplication (TIF) is consideredmedically necessaryfor individuals whenallof the following criteria are met:Confirmed diagnosis of GERD;andHiatal hernia not greater than 2 cm;andHill grade 1 or 2;andNo esophageal motility disorder (for example, achalasia, scleroderma);andpH or pH impedance findings are consistent with reflux;andDoes not have severe reflux esophagitis (Los Angeles grade C or D).
- Confirmed diagnosis of GERD;and
6 Active Policies
ANTHEM-SURG.00047 — SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia or Gastroparesis
ANTHEM-CG-SURG-101 — CG-SURG-101 Ablative Techniques as a Treatment for Barrettâs Esophagus
ANTHEM-LAB.00037 — LAB.00037 Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
ANTHEM-CG-SURG-83 — CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
Related Codes
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