Medical Policy Update

Revised Medical Policies

Medical Policy VIII.7 Adjustable Cranial Orthoses for Plagiocephaly and Craniosynostosis

III. Use of an adjustable cranial orthosis as a treatment of persistent plagiocephaly or brachycephaly 
without synostosis may be considered medically necessary when all of the following conditions have 
been met:

• the individual is between 3 and 18 months old
• documented failure of conservative therapy (repositioning and physical therapy) of at least 2 
  months duration
• the individual has a cephalic index that is at least two standard deviations above or below the 
  mean for the appropriate gender and age.

Medical Policy III.239 Lower Esophageal Myotomy for Treatment of Achalasia

Effective Date: 9/1/2024 
Preauthorization Required: YES

1. Peroral endoscopic myotomy (POEM) may be considered medically necessary when ALL the 
   following criteria are met:
   1. The individual is 18 years of age or older; AND
   2. The individual has a diagnosis of spastic achalasia type III; AND
   3. Eckhardt symptom score is greater than three (see guidelines).
2. Peroral endoscopic myotomy (POEM) is considered investigational if the above criteria is not 
   met and for all other indications.
   

Guidelines

Eckardt score for symptomatic evaluation in achalasia:

Medical Policy III.239 Lower Esophageal Myotomy for Treatment of Achalasia and Gastroparesis

HTT Repeat Analysis

Additional policy statement:
III. Gastric peroral endoscopic myotomy (G-POEM) is considered investigational as a treatment for 
gastroparesis and all other indications