P0632 - Time to Peroral Endoscopic Myotomy (POEM); Impact of Provider and Patient Appeal and Insurance Approval

Sunday, October 24, 2021

3:30 PM – 7:00 PM PT

Location: Shoreline Exhibit Hall

Has Audio

Award: Presidential Poster Award

Presenting Author(s)

MUHAMMAD H. BASHIR, MD

Thomas Jefferson University Hospital
Charleston, WV, United States

Award: Presidential Poster Award

MUHAMMAD H. BASHIR, MD¹, Vincent Del Duca, ², Umma K. Fatema, ³, Divya Chalikonda, MD⁴, Alex Schlachterman, MD¹
¹Thomas Jefferson University Hospital, Philadelphia, PA; ²Thomas Jefferson University, Philadelphia, PA; ³Thomas Jefferson Medical School, Phiadelphia, PA; ⁴Thomas Jefferson University Hospitals, Philadelphia, PA

Introduction: Peroral Endoscopic Myotomy (POEM) is an increasingly common technique to treat esophageal and gastric motility disorders. Substantial literature exists to support its safety and efficacy. However, care of patients who may benefit from POEM is frequently delayed due to issues related to insurance approval. In these cases, a letter of medical necessity (LMN) from the provider and a patient letter of appeal (PLA) can be provided. We aim to determine the impact of these measures on time to POEM

Methods: We performed a single-center, retrospective cohort study at a tertiary care center. All patients who underwent esophageal POEM between 1/2019 and 6/2021 were included. Data were collected for indication of the procedure, time to POEM from initial clinic visit date, insurance carrier, letter of medical necessity and patient letter of appeal date. Results were analyzed using IBM SPSS™, version 28.

Results: 92 patients underwent esophageal POEM during the study period. Average time to POEM from initial clinic visit was 116.9 days. A letter of medical necessity (LMN) and a patient letter of appeal (PLA) was sent to respective health insurance carrier for 48 (52.2%) and 45 (48.9%) patients respectively. Mean days to POEM in the LMN group was 144.8 days compared to 86.6 days in the group which did not require a LMN (t(90)=-2.0, p=.047). PLA was also completed in 45/48 patients who had a LMN. Average time to POEM was 150.9 days in patients who had a PLA in addition to LMN which varied with significance from those who did not have a PLA (t(90)=-2.3, p=.023). 81 (88.0%) patients had POEM for the indication of achalasia, and there was no difference in time to POEM or need for LMN in patients with achalasia or without achalasia.

Discussion: Despite high quality scientific evidence and various gastrointestinal society guidelines, large proportion of patient experience long wait times prior to POEM procedure due to lack of insurance approval. LMN or PLA does not help reduce the insurance approval time. Development of CPT codes and insurance acceptance is essential to improve patient access to less invasive treatment options for achalasia.

		Letter of Medical Necessity (n=48)	No Letter of Medical Necessity (n=48)	Patient Letter of Appeal (n=45/48)	Total (n=92)	p-Value
All Indications	Mean days to POEM	144.8	86.6	150.9	116.9	0.047¹
Achalasia		43	38	41	81	0.634²
	Mean days to POEM	144.0	88.7	150.8	118.0
	Medicare Insurance	14	18	14	32
Other top 3 insurance carriers
	Aetna	8	3	3
	Blue Cross Blue Shield	6	4	4
	Horizon BC/BS	3	2	2

Table: Table 1. Duration to POEM and Insurance Characteristics of POEM Patients

1T-test comparing outcomes of those who had a letter of medical necessity compared to
those who did not
2Chi-square comparing need for a letter of medical necessity in those with achalasia compared to those with other indications

Disclosures:

MUHAMMAD BASHIR indicated no relevant financial relationships.

Vincent Del Duca indicated no relevant financial relationships.

Umma Fatema indicated no relevant financial relationships.

Divya Chalikonda indicated no relevant financial relationships.

Alex Schlachterman indicated no relevant financial relationships.

MUHAMMAD H. BASHIR, MD¹, Vincent Del Duca, ², Umma K. Fatema, ³, Divya Chalikonda, MD⁴, Alex Schlachterman, MD¹. P0632 - Time to Peroral Endoscopic Myotomy (POEM); Impact of Provider and Patient Appeal and Insurance Approval, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.