Medicare AdvantageCoverageLow impact
MA11.117, Peroral Endoscopic Myotomy (POEM) Procedures
Independence Blue Cross·Gastroenterology·Medical Policy
We identified it
Jun 19, 2026
Summary
Independence Blue Cross has reissued MA11.117 policy on Peroral Endoscopic Myotomy (POEM) procedures, reaffirming coverage for achalasia type III with specific clinical criteria (age 18+, Eckardt score >6, documented via esophageal manometry). No changes to coverage criteria, but billing teams must ensure claims include required documentation and diagnosis code K22.0. Variants (G-POEM, D-POEM, Z-POEM) remain experimental/investigational and non-covered.
Action Required
Immediately: Billing team must verify that all POEM claims (CPT 43497) for Medicare Advantage members include diagnosis code K22.0 and documentation confirming: (1) member age ≥18 years, (2) achalasia type III diagnosis via esophageal manometry, and (3) Eckardt symptom score >6. Do NOT bill CPT 43497 without meeting all three criteria or claims will be denied. Ensure claims for G-POEM, D-POEM, and Z-POEM (billed as CPT 43999 or 43499) are rejected as experimental/investigational. Update billing system edits and prior authorization templates to enforce these requirements. Train coding and billing staff on medical necessity criteria and required supporting documentation.