Gastric Pacing / Electrical Stimulation and Gastroesophageal Per Oral Endoscopic Myotomy (CPB 0678, reviewed 2026-10-21)

Verify current applicability of this policy review (dated 2026-10-21) by confirming with Aetna whether an effective date has been established for CPB 0678 changes. Billing and clinical teams should: (1) Ensure prior authorization processes require documentation of gastric emptying scintigraphy confirmation and failure of specified medication classes (2 of 3 prokinetics + 2 of 3 anti-emetics for ≥1 year) before approving CPT 43647, 43648, 43881, 43882, 64590 for gastric pacing/electrical stimulation claims; (2) Flag claims for POEM procedures (CPT 43497, 43180) as requiring achalasia or Zenker diverticulum diagnosis confirmation; (3) Deny or pend claims for G-POEM (gastric POEM) procedures unless all four eligibility criteria are documented: confirmed gastroparesis on GES (>60% retention at 2 hours or >10% at 4 hours), symptom duration >6 months, inadequate response to conservative treatment, and trial of ≥1 prokinetic agent; (4) Reject claims for experimental/investigational procedures including balloon dilation tests, EndoFLIP studies, temporary GES, transcutaneous gastric pacing, and G-POEM for non-gastroparesis indications; (5) Update billing system denials logic to reject claims for second gastric electrical stimulators as experimental. Without proper pre-claim verification of these criteria, claims will be denied or require costly rework. Establish a checklist in the EHR and billing system cross-references to link these CPT codes to required supporting documentation (gastric emptying studies, medication trial history, symptom duration records).