CommercialBilling CodesMedium impact
11.03.17a, Peroral Endoscopic Myotomy (POEM) Procedures
Independence Blue Cross·PA · Gastroenterology, General Surgery·Medical Policy
Effective date
Jan 5, 2026
We identified it
Jun 19, 2026
Summary
Independence Blue Cross updated policy 11.03.17a to replace CPT code 43999 with CPT code 43499 for diverticular peroral endoscopic myotomy (D-POEM) and zenker peroral endoscopic myotomy (Z-POEM) procedures. Both procedures remain classified as experimental/investigational and not covered. The medically necessary coverage criteria for standard POEM (achalasia type III with Eckardt score >6) remain unchanged.
Action Required
By January 5, 2026: Billing team must update billing system and encounter forms to replace CPT code 43999 with CPT code 43499 for D-POEM and Z-POEM procedures. Remove all references to 43999 from billing templates and system rules. Ensure claims for D-POEM and Z-POEM continue to be denied as experimental/investigational. Verify that CPT 43497 (standard POEM for achalasia type III) is set to require medical necessity documentation including esophageal manometry results and Eckardt score >6 before processing. Claims submitted with incorrect codes or without proper achalasia documentation will be denied.