LCD Reference Article Response To Comments Article

Response to Comments: Peroral Endoscopic Myotomy (POEM)

A58561

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A58561
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Article Title
Response to Comments: Peroral Endoscopic Myotomy (POEM)
Article Type
Response to Comments
Original Effective Date
01/14/2021
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The comment period for the Peroral Endoscopic Myotomy (POEM) DL38747 Local Coverage Determination (LCD) began on 9/3/20 and ended on 11/7/20. The notice period for L38747 begins on 1/14/21 and will become effective on 2/28/21. The comments below were received from the provider community.

Response To Comments

Number Comment Response
1

I want to express my appreciation to those responsible for the thoughtful and thorough evaluation of the POEM procedure in creating the POEM LCD.

However, I do want to provide the comment/concern regarding what appears at face value to be a lack of coverage for non-achalasia esophageal motility disorders, including diffuse esophageal spasm , jackhammer esophagus, and esophagogastric junction outlet obstruction.

To avoid any unnecessary repetition, I will simply draw the authors/reviewers to this review from one of our foremost journals, Clinical Gastroenterology and Hepatology, written by Peter Kahrilas and John Pandolfino, two of the foremost esophageal experts in the world, where they direct that achalasia treatment options are sometimes necessary for those patients who fail to respond to conservative and medical therapy. When achalasia treatment options are employed, POEM is an appropriate treatment option (as is surgical myotomy, with POEM being shown to be equally effective), and in some instances of jackhammer or diffuse esophageal spasm, POEM is the preferred treatment option due to its ability to tailor the esophageal myotomy to the affected length of circular muscle, and it avoids the significant morbidity of the trans-thoracic approach to the surgical myotomy.

Reference was provided for review.

Thank you for your informed comments regarding this policy.

Palmetto GBA recognizes that POEM is used to treat non-achalasia esophageal motility disorders such as DES, Hypercontractile (jackhammer) esophagus, and esophagogastric junction outlet obstruction.

However, given the limited peer-reviewed literature currently available, insufficient evidence exists to include these diagnoses for coverage at this time.

2

I would like to commend the proposed LCD covering POEM (per-oral endoscopic myotomy) in patients with idiopathic achalasia (types I, II, and III). I do, however, wish to express my strong recommendation that POEM also be covered for other achalasia syndromes, including esophagogastric junction outflow obstruction, distal esophageal spasm, and jackhammer esophagus. These are types of clinical achalasia syndromes referenced in the 2017 American Gastroenterological Association’s Clinical Practice Update on the use of POEM (reference 5 in the LCD). Quoting the authors, “We now conceptualize achalasia syndromes as involving the LES with or without obstructive physiology of the distal smooth muscle esophagus…For other achalasia syndromes, POEM should be considered as a treatment option of comparable efficacy to LHM…” Medical therapy is often of limited or no value in many of these disorders, and POEM is often by far the best treatment modality for patients with these achalasia syndromes.

Thank you for your informed comments regarding this policy.

Palmetto GBA recognizes that POEM is used to treat non-achalasia esophageal motility disorders such as DES, Hypercontractile (jackhammer) esophagus, and esophagogastric junction outlet obstruction.

However, given the limited peer-reviewed literature currently available, insufficient evidence exists to include these diagnoses for coverage at this time.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L38747 - Peroral Endoscopic Myotomy (POEM)
Related National Coverage Documents
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