CommercialCoverageLow impact
11.03.17, Peroral Endoscopic Myotomy (POEM) Procedures
Independence Blue Cross·Gastroenterology·Medical Policy
We identified it
Jun 19, 2026
Summary
Independence Blue Cross reissued Policy 11.03.17 on 07/09/2025 reaffirming coverage for Peroral Endoscopic Myotomy (POEM) procedures limited to achalasia type III cases meeting specific clinical criteria (age ≥18, Eckardt score >6, esophageal manometry confirmation). Variant procedures (G-POEM, D-POEM, Z-POEM) remain experimental/investigational and non-covered. This is a continuation of the existing policy with no substantive coverage changes.
Action Required
No immediate action required. This is a policy reissuance confirming the Company's existing position on POEM coverage. Billing team should verify current billing system reflects the covered criteria: CPT 43497 requires diagnosis code K22.0 (achalasia of cardia) with documentation of achalasia type III diagnosis and Eckardt symptom score >6. Confirm that unlisted codes 43999 and 43499 (for G-POEM, D-POEM, Z-POEM variants) are configured to deny as experimental/investigational. No claim submission workflow changes needed unless prior authorization was not previously required—verify your current system configuration matches this policy's medical necessity criteria.