Medicare AdvantageBilling CodesHigh impact
MA11.117a, Peroral Endoscopic Myotomy (POEM) Procedures
Independence Blue Cross·Gastroenterology, General Surgery·Medical Policy
Effective date
Jan 5, 2026
We identified it
Sep 3, 2026
Summary
Independence Blue Cross updated MA11.117a to replace CPT code 43999 with CPT code 43499 for diverticular peroral endoscopic myotomy (D-POEM) and zenker peroral endoscopic myotomy (Z-POEM) procedures, effective January 5, 2026. POEM remains covered only for achalasia type III with Eckardt symptom score >6 in patients age 18+, while G-POEM, D-POEM, and Z-POEM remain non-covered/experimental.
Action Required
By January 5, 2026: Billing team must update all billing software, claim submission systems, and internal billing rules to discontinue use of CPT 43999 and replace it with CPT 43499 for D-POEM and Z-POEM procedures. Update internal billing guidelines and provider education materials to reflect the new code. Verify that claims submitted after the effective date use only CPT 43497 (medically necessary POEM for achalasia type III) or CPT 43499 (experimental D-POEM and Z-POEM, non-covered). Confirm that CPT 43999 is no longer used for these services. Claims submitted with the old CPT 43999 for D-POEM/Z-POEM after January 5, 2026 may be denied or require rework. Additionally, ensure all POEM claims include documentation of achalasia diagnosis (K22.0), patient age ≥18 years, achalasia type III confirmation via esophageal manometry, and Eckardt symptom score >6 to support medical necessity for coverage.