Medicare AdvantageBilling CodesMedium impact
MA11.117a, Peroral Endoscopic Myotomy (POEM) Procedures
Independence Blue Cross·Gastroenterology, General Surgery·Medical Policy
Effective date
Jan 5, 2026
We identified it
Jun 19, 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. The medical necessity coverage criteria for standard POEM (CPT 43497) remain unchanged, requiring achalasia type III diagnosis, Eckardt symptom score >6, and age ≥18 years. All variants except standard POEM remain experimental/investigational and non-covered.
Action Required
By January 5, 2026: Billing team must update all billing software and claim submission systems to discontinue use of CPT code 43999 for D-POEM and Z-POEM procedures. Replace all instances of CPT 43999 with CPT code 43499 for these procedures. Audit any open or pending claims using CPT 43999 and resubmit with corrected code 43499. Update internal billing guidelines and provider documentation templates to reflect the code change. Educate providers and clinical staff on the new billing code. Note: All D-POEM, Z-POEM, and G-POEM procedures remain experimental/investigational and not covered regardless of code used; only standard POEM (CPT 43497) with achalasia type III diagnosis and Eckardt score >6 is covered.