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 reissued MA11.117 on 07/09/2025 to reaffirm its continuing position on POEM procedures. Coverage remains limited to achalasia type III (spastic) with Eckardt symptom score >6 in patients ≥18 years old using CPT 43497. All other POEM variations (G-POEM, D-POEM, Z-POEM) remain experimental/investigational and not covered. No substantive coverage criteria changes from prior versions.
Action Required
No immediate action required. This is a policy reaffirmation with no new coverage criteria or billing code changes. Billing team should verify internal records reflect: (1) CPT 43497 requires prior authorization with documentation of achalasia type III diagnosis (ICD-10 K22.0) and Eckardt score >6; (2) CPT 43999 and 43499 (G-POEM, D-POEM, Z-POEM) are non-covered experimental procedures and should be denied; (3) Patient age ≥18 years must be verified. Monitor for any future updates beyond the 07/09/2025 reissue date.