Insurance denial of POEM ‘inappropriate’ in face of evidence

WASHINGTON — With 39% of patients denied coverage of per oral endoscopic myotomy and required to undergo laparoscopic Heller myotomy to treat functional esophageal outflow obstruction despite mounting evidence of benefits to the contrary, a presenter at Digestive Disease Week 2018 deemed it ‘inappropriate’ and called for a change.

Perspective from John R. Saltzman, MD, FACP, FACG, FASGE, AGAF

“In light of the excellent short- and long-term outcomes of POEM that have been demonstrated in many series and the benefits compared to LHM that we have demonstrated here, we contend that continued denial by insurance providers is inappropriate,” Ahmed Zihni, MD, MPH, of The Oregon Clinic, said during his presentation.

In looking at esophageal myotomies from 2012 to 2016, Zihni and colleagues identified 261 patients who were offered both POEM and LHM. He showed that 216 of the patients preferred to undergo POEM while 45 preferred LHM. Yet, when looking at final procedure performed, 187 patients underwent POEM and 74 underwent LHM. In the cohort of patients with achalasia, the percentage increased to 52%.

“The discrepancy between preference and the procedure they underwent was due to insurance coverage denial in all cases,” Zihni said.

He showed that while the volume of POEM procedures has remained fairly stable since 2013, the rate of LHM doubled from 2014 to 2015 and 2016.

“This phenomenon was driven entirely by insurance coverage denial for our patients,” Zihni said.

He showed significant advantages of POEM over LHM in this cohort, including shorter operative time, shorter length of stay, fewer complications, superior symptom improvement and decreased opioid requirement on discharge.

“Our group and the foregut community at large – represented in this room – seek to practice precision medicine, tailoring our treatments to individual patients. As such, Heller myotomy is a better option for some patients. POEM is a better option for others. And many patients are good candidates for both procedures,” Zihni said. When patients are candidates for either procedure, they are “offered both in a treatment dialogue between surgeon and patient. However, the choice doesn’t always rest with the surgeon and patient. We’ve seen insurance companies deny coverage for POEM, which ends up impacting the procedure patients receive.” – by Katrina Altersitz

Reference :

Zihni A, et al. Abstract 547. Presented at: Digestive Disease Week; June 2-5, 2018; Washington, D.C.

Disclosure: Zihni reports no relevant financial disclosures.

Perspective

John R. Saltzman, MD, FACP, FACG, FASGE, AGAF

This is an important topic because insurers do need to control their expenditures in this era of escalating health care costs. They need to maintain their premiums and keep them from rising excessively, but at the same time, there are new, innovative areas of care emerging. Insurers are faced with deciding which to cover and which to deny.

Because of these pressures to keep costs down, insurers often require a very high degree of evidence, including randomized controlled trials and adoption by society guidelines before they will agree to pay for emerging techniques and technology. However, in those situations where evidence is strongly supportive of improved patient outcomes and/or decreased overall costs of care, they should pay.

The data are overwhelming that POEM is effective, safe and overall associated with less costs than a traditional surgical approach. It would behoove the medical directors of insurance companies to look at POEM specifically and consider overall costs of care rather than the just the costs of the procedure itself. In doing so, we should see more coverage by insurers of POEM for the treatment of achalasia.

John R. Saltzman, MD, FACP, FACG, FASGE, AGAF

Professor of Medicine

Harvard Medical School

Brigham and Women's Hospital

Disclosures: