SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia or Gastroparesis

This policy addresses transendoscopic therapies for GERD, dysphagia, and gastroparesis, specifically peroral endoscopic myotomy (POEM) and transoral incisionless fundoplication (TIF). Coverage is provided for POEM when all are met: primary achalasia diagnosis, used as an alternative to pneumatic dilation or surgical myotomy, and Eckardt score >3; and for TIF when all are met: confirmed GERD, hiatal hernia ≤2 cm, Hill grade 1–2, no esophageal motility disorder, objective pH/pH-impedance evidence of reflux, and no severe esophagitis (LA grade C or D). POEM, TIF, or G-POEM are not medically necessary when criteria are not met (G-POEM otherwise not medically necessary), and the following are investigational/not medically necessary for all indications: endoscopic submucosal bulking injections, transendoscopic gastroplasty, and transesophageal radiofrequency therapy (excluding RFA for Barrett’s esophagus).

"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 propo..."